chap 45 Flashcards

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client?
a. Alteplase (Activase)

b. Clopidogrel (Plavix)

c. Heparin sodium
d. Mannitol (Osmitrol)

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond?
a. Most of these types of blood clots come from the heart.
b. Some of the blood clots may have gone to your heart too.

c. We need to see if your heart is strong enough for therapy.

d. Your heart may have been damaged in the stroke too.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client?
a. Assess for bladder retention and/or incontinence.
b. Listen to the clients lungs after eating or drinking.

c. Prop the clients right side up when sitting in a chair.
d. Rotate the clients meal tray when the client stops eating.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?
a. Loss of bladder control

b. Other medical conditions

c. Progression of symptoms

d. Time of symptom onset

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority?

a. Assess for contraindications to fibrinolytics.
b. Ensure that informed consent is on the chart.
c. Perform a full neurologic assessment.

d. Review the clients medication lists.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority?

a. Administer pain medication.
b. Assess the clients vital signs.

c. Notify the Rapid Response Team.

d. Raise the head of the bed.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best?

a. Have the student ask the client if it is desired or not.
b. Inform the student that the docusate should be given.
c. Tell the student to document the rationale.
d. Tell the student to give it unless the client refuses.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks

c. Has clear lung sounds on auscultation

d. Gains 2 pounds after 1 week

A client with a stroke has damage to Brocas area. What intervention to promote communication is best for this client?
a. Assess whether or not the client can write.
b. Communicate using yes-or-no questions.

c. Reinforce speech therapy exercises.
d. Remind the client not to use neologisms.

A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client?
a. Impending brain herniation
b. Poor prognosis and cognitive function

c. Probable complete recovery
d. Unable to tell from this information

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority?

a. Call the provider or Rapid Response Team.

b. Increase the rate of the IV fluid administration.
c. Notify respiratory therapy for a breathing treatment.

d. Prepare to give IV pain medication.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first?
a. Client with a Glasgow Coma Scale score that was 10 and is now is 8
b. Client with a Glasgow Coma Scale score that was 9 and is now is 12

c. Client with a moderate brain injury who is amnesic for the event

d. Client who is requesting pain medication for a headache

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is intolerable. What action by the nurse is best?
a. Explain that personality changes are common following brain injuries.

b. Ask the client why he or she is acting out and behaving differently.
c. Refer the client and spouse to a head injury support group.
d. Tell the spouse this is expected and he or she will have to learn to cope.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?

a. Client with cerebral perfusion pressure of 72 mm Hg
b. Client who has a Glasgow Coma Scale score of 12
c. Client with a PaCO2 of 36 mm Hg who is on a ventilator

d. Client who has a temperature of 102 F (38.9 C)

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?

a. Client with a core temperature of 95 F (35 C) for 2 days
b. Client in a coma for 2 weeks from a motor vehicle crash

c. Client who is found unresponsive in a remote area of a field by a hunter

d. Client with a systolic blood pressure of 92 mm Hg since admission

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer?
a. Carbamazepine (Tegretol)
b. Dexmedetomidine (Precedex)

c. Diazepam (Valium)

d. Mannitol (Osmitrol)

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full- time caregiver. What statement by the spouse would lead the nurse to provide further education on home care?

a. I know I can take care of all these needs by myself.
b. I need to seek counseling because I am very angry.

c. Hopefully things will improve gradually over time. d. With respite care and support, I think I can do this.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
a. Ensure that informed consent is on the chart.
b. Document these findings in the clients record.

c. Give the prescribed preprocedure sedation.
d. Notify the provider of the findings immediately.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best?
a. Assess the clients magnesium level.
b. Assess the clients sodium level.

c. Increase the rate of the IV infusion.

d. Provide oral care every hour.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the clients score to be 36. How should the nurse plan care for this client?
a. The client will need near-total care.
b. The client will need cuing only.

c. The client will need safety precautions.

d. The client will be discharged home.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
a. Increased pressure from the abscess can cause seizures.
b. Preventing febrile seizures with an abscess is important.

c. Seizures always occur in clients with brain abscesses.

d. This drug is used to sedate the client with an abscess.

A client has an intraventricular catheter. What action by the nurse takes priority?

a. Document intracranial pressure readings.
b. Perform hand hygiene before client care.
c. Measure intracranial pressure per hospital policy.

d. Teach the client and family about the device.

A client has a subarachnoid bolt. What action by the nurse is most important?

a. Balancing and recalibrating the device
b. Documenting intracranial pressure readings
c. Handling the fiberoptic cable with care to avoid breakage

d. Monitoring the clients phlebostatic axis

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke?
a. A 27-year-old heavy cocaine user
b. A 30-year-old who drinks a beer a day

c. A 40-year-old who uses seasonal antihistamines

d. A 65-year-old who is active and on no medications

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the clients record. What action by the nurse is best?
a. Ask the client how long ago the clip was placed.
b. Have the client sign an informed consent form.

c. Inform the provider about the aneurysm clip.
d. Reschedule the client for computed tomography.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first?
a. Client who has been diagnosed with meningitis with a fever of 101 F (38.3 C)
b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix)

c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate

d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client?
a. Can ambulate independently
b. May have trouble swallowing

c. Needs frequent re-orientation

d. Will need near-total care

After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care?
a. Ambulate only with a gait belt.
b. Encourage double swallowing.

c. Monitor lung sounds after eating.

d. Perform post-void residuals.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The clients mental status is deteriorating. What action by the nurse is most appropriate?
a. Attempt to find the family to sign a consent.
b. Inform the provider that the procedure cannot occur.

c. Nothing; no consent is needed in an emergency.

d. Sign the consent form for the client.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?
a. Inability to communicate
b. Nutritional deficit
c. Risk for acquiring an infection
d. Risk for skin breakdown

A nursing student studying the neurologic system learns which information? (Select all that apply.)

a. An aneurysm is a ballooning in a weakened part of an arterial wall.
b. An arteriovenous malformation is the usual cause of strokes.
c. Intracerebral hemorrhage is bleeding directly into the brain.

d. Reduced perfusion from vasospasm often makes stroke worse.

e. Subarachnoid hemorrhage is caused by high blood pressure.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)
a. Alcohol intake
b. Diabetes

c. High-fat diet

d. Obesity
e. Smoking

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assess neurologic status with the Glasgow Coma Scale.
b. Check and document oxygen saturation every 1 to 2 hours.

c. Cluster client care to allow periods of uninterrupted rest.
d. Elevate the head of the bed to 45 degrees to prevent aspiration.
e. Position the client supine with the head in a neutral midline position.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)
a. Discharging the client on a statin medication

b. Providing the client with comprehensive therapies

c. Meeting goals for nutrition within 1 week
d. Providing and charting stroke education
e. Preventing venous thromboembolism

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.)
a. A client with a moderate trauma may need hospitalization.
b. A Glasgow Coma Scale score of 10 indicates a mild brain injury.

c. Only open head injuries can cause a severe TBI.
d. A client with a Glasgow Coma Scale score of 3 has severe TBI.

e. The terms mild TBI and concussion have similar meanings.

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.)
a. Admission can overwhelm the coping mechanisms for older clients.
b. Alcohol is typically involved in most traumatic brain injuries for this age group.

c. These clients are more susceptible to systemic and wound infections.

d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Applying a cool washcloth to the head
b. Assisting the client to a position of comfort

c. Keeping voices soft and soothing
d. Maintaining low lighting in the room

e. Providing antipyretics for fever

A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)
a. Client who exhibits extreme emotional lability
b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38

c. Client with mild forgetfulness and a slight limp
d. Client who has a past hospitalization for a suicide attempt

e. Client who is unable to walk or eat 3 weeks post-stroke

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the clients care? (Select all that apply.)
a. Assess tube placement per agency policy.
b. Keep the head of the bed elevated at least 30 degrees.
c. Listen to lung sounds at least every 4 hours.
d. Run continuous feedings on a feeding pump.
e. Use blue dye to determine proper placement.

A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)
a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches

b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence

c. Client who had a coil procedure who says that there will be no problem following up for 1 year
d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation
e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.)

a. Does not want to purchase a thermometer
b. Is allergic to acetaminophen (Tylenol)

c. Laughing, says Strenuous? Whats that?
d. Lives alone and is new in town with no friends

e. Plans to have a beer and go to bed once home