Week 7 Chap 61 and 62
A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months
A
A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. The client should mobilize as soon as physically able. B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C. The client should remain on bed rest until the client expresses a desire to mobilize. D. Lack of mobility will greatly increase the client's risk of stroke recurrence.
A
A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.
A
Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? A. Positioning the client to avoid intercranial pressure (ICP) B. Maximizing partial pressure of carbon dioxide (PaCO2) C. Administering hypertonic intravenous (IV) solution D. Initiating early mobilization
A
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.
A
The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting
A
The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? A. Ischemic stroke B. Decrease inflammation C. Hemorrhagic stroke D. Hypertension
A
The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? A. Seizure B. Hypernatremia C. Airway collapse D. Pneumothorax
A
When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Frustration around changes in function and communication B. Unmet physiologic needs C. Changes in brain activity during sleep and wakefulness D. Temporary changes in metabolism
A
The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. A. Providing frequent small meals rather than three larger meals B. Teaching the client to perform deep breathing and coughing exercises. C. Keeping a urinary catheter in place for the full duration of recovery. D. Limiting intake of insoluble fiber, carbohydrates, and simple sugars. E. Encourage the client to stay in bed and assist with turning and repositioning.
A, B
During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A. National Institutes of Health Stroke Scale (NIHSS) score B. Race C. LOC at time of admission D. Gender E. Age
A, C, E
A patient has developed diabetes insipidus after having increased ICP following head trauma. When developing a teaching plan for this patient the nurse should include information about which hormone, commonly lacking in patients with diabetes insipidus? A) Antidiuretic hormone (ADH) B) Thyroid-stimulating hormone (TSH) C) Follicle-stimulating hormone (FSH) D) Luteinizing hormone (LH)
ANS: A ADH is the hormone lacking in diabetes insipidus. The patient's TSH, FSH, and LH levels won't be affected.
Your patient is scheduled for intracranial surgery in the morning. You know that it is important that the patient has adequate preparation for surgery to reduce what? A) Postoperative complications B) Length of time under anesthesia C) Establishing expectations that are too high D) Length of time in the hospital
ANS: A Adequate preparation for surgery, with attention to the patient's physical and emotional status, can reduce the risk of anxiety, fear, and postoperative complications. Adequate preparation for surgery does not reduce the length of time under anesthesia or in the hospital and it does not establish expectations that are too high.
You have a patient with an altered level of consciousness. What would be your first action when assessing this patient? A) Assessing the verbal response B) Assessing if the patient follows commands C) Assessing whether the patient will open their eyes D) Assessing response to pain
ANS: A Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place. Therefore options B, C, and D are incorrect.
When the nurse observes that the post-craniotomy patient is unresponsive to and unaware of environmental stimuli, the nurse uses which of the following terms to describe the patient in his documentation? A) Unresponsive B) Comatose C) Demonstrating akinetic mutism D) In a persistent vegetative state
ANS: A Coma is a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli, although nonpurposeful responses to painful stimuli and brainstem reflexes may be present. Persistent vegetative state is a condition in which the patient is described as wakeful but devoid of conscious content, without cognitive or affective mental function. In unresponsiveness, the patient is unresponsive to and unaware of environmental stimuli. Akinetic mutism is a state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes.
The nursing instructor is discussing increased intracranial pressure (ICP) with the senior nursing students. What would the instructor be correct in telling the students is an early clinical manifestation of ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex
ANS: A Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brainstem reflexes such as the corneal reflex.
When caring for a patient with a neurologic impairment and his or her family, what are the mutual goals? A) Achieve as high a level of function as possible. B) Enhance the quantity of life. C) Teach the family proper care of the patient. D) Provide community assistance.
ANS: A The goals are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. It is not a goal to enhance the quantity of the patient's life or provide community assistance. The scenario does not indicate that the patient needs to be taken care of by the family.
When caring for a patient with increased ICP the nurse must monitor for possible secondary complications. One possible complication of increased ICP is SIADH. What nursing interventions would the nurse initiate if the patient developed SIADH? A) Fluid restriction B) Fluid replacement C) Electrolyte replacement D) Electrolyte restriction
ANS: A The nurse also assesses for complications of increased ICP, including diabetes insipidus and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. You do not "restrict" electrolytes with patients, you monitor them. Diabetes insipidus requires fluid and electrolyte replacement.
A patient with a newly diagnosed seizure disorder is to be discharged home in the morning. You are preparing patient/family teaching and know that a priority to teach the family is what? A) Place the patient in a side-lying position. B) Pad the bed rails. C) Keep a bite block nearby at all times. D) Withhold medication after a seizure.
ANS: A To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. Most patients at home do not have bed rails; a bite block is no longer used in the care of seizure patients; you do not withhold medication from a seizure patient.
You are caring for a patient who has had transsphenoidal surgery. You know that when a patient has transsphenoidal surgery it is generally for a problem with what? A) Pituitary B) Thalamus C) Hypothalamus D) Foreamen ovale
ANS: A Transsphenoidal surgery is a surgical approach to the pituitary via the sphenoid sinuses.
The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patient's admission orders? (Mark all that apply.) A) Transcranial Doppler flow study B) Cerebral angiography C) MRI D) Cranial radiography E) EMG
ANS: A, B, C Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.
When caring for a patient with a neurologic dysfunction, what complications must the nurse monitor for? (Mark all that apply.) A) Contractures B) Interrupted family processes C) Pressure ulcer D) DVT E) Pneumonia
ANS: A, C, D, E Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. Interrupted family processes is a nursing diagnosis, not a possible complication.
What diagnostic test is contraindicated in a patient exhibiting clinical manifestations of increased intracranial pressure? A) CT scan B) Lumbar puncture C) MRI D) Venous Doppler studies
ANS: B A lumbar puncture in a client with increased intracranial pressure (ICP) may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. A CT scan, MRI, and venous Doppler are considered noninvasive procedures and would not affect the intracranial pressure itself.
A nurse is caring for a patient admitted with cluster headaches. The nurse knows that in the early phase of a cluster headache what is required? A) Dim lighting B) Abortive medication therapy C) Quiet D) Rest
ANS: B A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Dim lighting, quiet, and rest are necessary for migraines; they are not required in the early phase of a cluster headache.
A clinic nurse is caring for a patient diagnosed with migraine headaches. When doing patient teaching, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about alcohol's effects? A) Alcohol causes hormone fluctuation. B) Alcohol causes vasodilation of the blood vessels. C) Alcohol has an excitatory effect on the CNS. D) Alcohol diminishes endorphins in the brain.
ANS: B Alcohol causes vasodilation of the blood vessels. Alcohol has a depressant effect on the central nervous system (CNS). Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.
A school nurse is called to the playground where a 6-year-old girl has fallen off the slide. When the nurse gets to the playground the girl is exhibiting jerking motions in her left arm and leg. The girl is unconscious. How would the nurse document the girl's activity in her chart at school? A) Simple partial seizure B) Complex partial seizure C) Complex generalized seizure D) Simple generalized seizure
ANS: B In a simple partial seizure, consciousness remains intact, whereas in a complex partial seizure, consciousness is impaired.
While completing a health history on a newly diagnosed patient with generalized seizure disorder the nurse would assess for what characteristic associated with the post-ictal state? A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity
ANS: B In the post-ictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles which occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the emergency department. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The priority nursing evaluations, when assessing level of consciousness in this patient, would be based on what? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status exam
ANS: B Level of consciousness (LOC), a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Refer to Chart 63-4. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status exam would be part of the neurologic examination for this patient, but would not be the priority in evaluating level of consciousness.
When caring for an unconscious patient what nursing intervention takes highest priority? A) Inserting an indwelling urinary catheter B) Maintaining a patent airway C) Putting a nasogastric (NG) tube in place D) Administering an enema daily
ANS: B Maintaining a patent airway always takes top priority. An indwelling urinary catheter and NG tube can be inserted after airway patency has been established. Enemas should be avoided because of the danger of increasing intracranial pressure.
The nurse is caring for a patient on the neurologic unit who is in status epilepticus. What medications does the nurse know may be given to halt the seizure immediately? A) Intravenous phenobarbitol (Luminal) B) Intravenous diazepam (Valium) C) Oral lorazepam (Ativan) D) Oral phenytoin (Dilantin)
ANS: B Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes intravenous diazepam (Valium) and intravenous lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbitol) are given later to maintain a seizure-free state.
In what position should the nurse place the patient following a craniotomy with a supratentorial approach? A) Position patient flat B) Maintain HOB elevated at 30 to 45 degrees C) Position patient in prone position D) Maintain bed in Trendelenburg position
ANS: B The patient undergoing a craniotomy with a supratentorial (above the tentorium) approach should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment.
The nurse is caring for a postop craniotomy patient. When writing the plan of care, the patient has a diagnosis of Deficient fluid volume related to fluid restriction related to osmotic diuretic use. What would be an appropriate intervention for this diagnosis? A) Change the patient's position as indicated B) Monitor serum electrolytes C) Maintain NPO status D) Monitor arterial blood gas values
ANS: B The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral edema. Changing the patient's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of Risk for imbalanced fluid volume.
A patient with increased intracranial pressure (ICP) has a ventriculostomy for monitoring their ICP. The patient is now exhibiting nuchal rigidity and photophobia. What would the nurse be correct in suspecting has become a complication? A) Encephalitis B) CSF leak C) Meningitis D) Clotted catheter
ANS: C Complications of a ventriculostomy include ventricular infection meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis. Therefore options A, B, and D are incorrect
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to your unit. You would be correct in assessing for what adverse effect of this therapy? A) Bradycardia B) Diarrhea C) Gingivival hyperplasia D) Weight gain
ANS: C Gingivival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin) use. Bradycardia, diarrhea, and weight gain are not associated with dilantin therapy. Adverse effects noted with dilantin therapy are tachycardia, constipation, and weight loss
The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? A) Solumedrol B) Dextromethorphan C) Dexamethasone D) Mannitol
ANS: C If a brain tumor is the cause of the increased ICP, corticosteroids (eg, dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and mannitol, an osmotic diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.
A priority in postoperative management of a patient who has had intracranial surgery is what? A) Reducing pain B) Reducing periorbital edema C) Monitoring ICP D) Preserving seizures
ANS: C Ongoing postoperative management is aimed at detecting and reducing cerebral edema, relieving pain and preventing seizures, and monitoring ICP and neurologic status.
A nurse is admitting a patient with a severe migraine headache. The patient has a history of myocardial infarction in the past year. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig)
ANS: C Sumatriptan may cause chest pain and is contraindicated in patients with ischemic heart disease. Adverse effects of sumatriptan succinate include angina, chest pressure, and chest tightness. None of the triptan medications should be taken concurrently with medications containing ergotamine (vascular headache suppressant) due to the potential for a prolonged vasoactive reaction. Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.
You have admitted a patient to the Neurolog Intensive Care Unit with a brainstem herniation. The patient is now exhibiting an altered level of consciousness. The nurse has determined that the patient's mean arterial pressure (MAP) is 60 with an intracranial pressure (ICP) reading of 5 mm Hg. The nurse would be correct in determining the cerebral perfusion pressure (CPP) as which of the following values? A) Normal B) High C) Low D) Compensating
ANS: C The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. A lower than normal CPP indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion.
A patient is being admitted to the Neuro ICU following an acute head injury. The patient has cerebral edema. The nurse would expect to administer what priority medications to reduce cerebral edema? A) Hydrochlorothiazide (HydroDIURIL) B) Lasix (Furosemide) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)
ANS: C The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reduces the volume of brain and extracellular fluid. Spirolactone, Lasix, and Hydrochorothiazide are used in the treatment of CHF and hypertension.
During their pathophysiology class the nursing students study seizures. How might the instructor best describe the cause of a seizure? A) Uncontrolled normal electrical charges throughout the brain B) A dysrhythmia in the motor strip of the brain C) A dysrhythmia in the nerve cells in one section of the brain D) Abnormal, recurring, controlled electrical charges in the brain
ANS: C The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by normal electrical charges throughout the brain or controlled electrical charges in the brain. Option B could be correct, but not all seizures arise in the motor strip of the brain.
A patient with a seizure disorder is presenting having a generalized seizure. An appropriate nursing intervention during the seizure would include what? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing.
ANS: D An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of Ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.
ANS: D An expected outcome of the diagnosis of Ineffective tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of Disturbed sensory perception. The outcome of Registers normal body temperature relates to the diagnosis of Potential for ineffective thermoregulation. Body image disturbance would have a potential outcome of Pays attention to grooming.
You are discharging a patient home after supratentorial removal of a pituitary mass. What medication would you expect to have ordered prophylactically for this patient? A) Prednisone B) Dexamethasone C) Cafergot D) Phentoin
ANS: D Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after these procedures. Prednisone and dexamethasone are steroids. Cafergot is used in the treatment of migraines.
A patient is considered terminal after being involved in a motor vehicle accident in which they received massive trauma to the head. As the patient's ICP increases and condition worsens, the family asks you what indications of approaching death will there be. What would be your best response? A) "There is a change in the pattern of their respirations." B) "Projectile vomiting and hemiplegia usually occur just before death." C) "Posturing may develop as pressure on the brainstem increases." D) "Loss of brainstem reflexes is a sign of approaching death."
ANS: D As ICP increases, the patient's condition worsens, as manifested by the following signs and symptoms: the LOC continues to deteriorate until the patient is comatose. The pulse rate and respiratory rate decrease or become erratic, and the blood pressure and temperature increase. The pulse pressure (the difference between the systolic and the diastolic pressures) widens. The pulse fluctuates rapidly, varying from bradycardia to tachycardia. Altered respiratory patterns develop, including Cheyne-Stokes breathing (rhythmic waxing and waning of rate and depth of respirations alternating with brief periods of apnea) and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). Projectile vomiting may occur with increased pressure on the reflex center in the medulla. Hemiplegia or decorticate or decerebrate posturing may develop as pressure on the brainstem increases. Bilateral flaccidity occurs before death. Loss of brainstem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death.
What should the nurse suspect when hourly assessment of urine output on a postcraniotomy patient exhibits a urine output from a catheter of 1500 mL for 2 consecutive hours? A) Cushing's syndrome. B) Syndrome of inappropriate antidiuretic hormone C) Adrenal crisis. D) Diabetes insipidus.
ANS: D Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.
During the examination of an unconscious patient, the nurse notices that the patient's pupils are fixed and dilated. What is the clinical significance of the nurse's finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.
ANS: D Pupils that are fixed and dilated indicate injury at the midbrain level.
How does the nurse help the patient and family gain control of their lives? A) By providing educational resources in the community B) By offering referrals to community social clubs C) By introducing the patient to other neurologically impaired people in the community D) By collaborating with other members of the health care team
ANS: D The nurse collaborates with other members of the health care team to provide essential care, offer a variety of solutions to problems, help the patient and family gain control of their lives, and explore the educational and supportive resources available in the community. The nurse does not provide educational resources in the community, provide introductions to others who are neurologically impaired, or refer patients to social clubs
The causes of acquired seizures include what? (Mark all that apply.) A) Cerebrovascular disease B) Metabolic and toxic conditions C) Hypernatremia D) Brain tumor E) Drug and alcohol addiction
ANS: D The specific causes of seizures are varied and can be categorized as idiopathic (genetic, developmental defects) and acquired. Causes of acquired seizures include cerebrovascular disease; hypoxemia of any cause, including vascular insufficiency; fever (childhood); head injury; hypertension; central nervous system infections; metabolic and toxic conditions (eg, renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure); brain tumor; drug and alcohol withdrawal; and allergies.
A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? A. Support the client's full body weight with a waist belt during ambulation. B. Have a colleague follow the client closely with a wheelchair. C. Avoid mobilizing the client in the early morning or late evening. D. Ensure that the client's family members do not participate in mobilization.
B
A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? A. Botulinum toxin type A and heat B. Baclofen and stretching C. Amitriptyline and splinting D. Corticosteroids and acupuncture
B
A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic stroke B. Right hemispheric stroke C. Hemorrhagic stroke D. Left hemispheric stroke
B
A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.
B
A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? A. Immediate intubation and urinary catheter placement B. Supplemental oxygen and monitoring blood glucose levels C. Antipyretics in order to keep the client in a state of hypothermia D. Antihypertensive medications and vital signs every two hours
B
A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? A. "We are trying to help the client be as useful as possible." B. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." C. "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home." D. "Rehabilitation means helping clients do exactly what they did before their stroke."
B
The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath
B
The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supraventricular tachycardia D. Bundle branch block
B
When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck
B
A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Encourage the client to increase his/her intake of water and juice. B. Assist the client out of bed and into the chair for meals. C. Instruct the client to tuck his/her chin towards their chest when swallowing. D. Request a swallowing assessment by a speech therapist before the client's discharge E. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.
B, C
A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? A. How to differentiate between hemorrhagic and ischemic stroke B. Risk factors for ischemic stroke C. How to correctly modify the home environment D. Techniques for adjusting the client's medication dosages at home
C
A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA
C
A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The nurse gives direction to get out of bed but the client does not understand. B. The client points and gestures to an object needed on the overhead table. C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. D. The client sits up and turns to one side to see the object and states what is needed.
C
A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures
C
A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? A. Homonymous hemianopsia B. Receptive aphasia C. Agnosia D. Hemiplegia
C
The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? A. The client's hip joint should be maintained in a flexed position. B. The client should be in a supine position unless ambulating. C. The client should be placed in a prone position for 15 to 30 minutes several times a day. D. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.
C
The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. Confusion B. Uncertainty C. Depression D. Disassociation
C
The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed. D. Drowsiness is normal for the first week after discharge.
C
The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? A. Naproxen 250 PO b.i.d. B. Calcium carbonate 1,000 mg PO b.i.d. C. Aspirin 81 mg PO o.d. D. Lorazepam 1 mg SL b.i.d. PRN
C
The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps. Place the steps in the order in which they occur. All options must be used. 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated A. 635241 B. 352416 C. 236145 D. 162534
C
A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the health care provider immediately.
D
A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low. B. Place the client's clock on the affected side. C. Approach the client on the side where vision is impaired. D. Place the client's extremities where the client can see them.
D
A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B. Elevation of the arm and hand can lead to further complications associated with edema. C. Passively exercising the affected extremity is avoided in order to minimize pain. D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
D
A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment
D
A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? A. Cerebral cortex B. Temporal lobe C. Central sulcus D. Penumbra region
D
A nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. Which is true of hemorrhagic stroke? A. Occurs with vascular occlusion. B. Is also known as thrombotic stroke. C. Can be known as lacunar strokes. D. Can occur in the subarachnoid space.
D
A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? A. Adult failure to thrive B. Post-trauma syndrome C. Hyperthermia D. Disturbed sensory perception
D
What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day. B. Keep activity limited, as the client may be overstimulated. C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.
D