Ch. 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 client’s 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)
ANS: B
This client’s manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.
DIF: Remembering/Knowledge REF: 930
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.”
ANS: A
An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.
DIF: Understanding/Comprehension REF: 931
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 client’s lungs after eating or drinking.
c.
Prop the client’s right side up when sitting in a chair.
d.
Rotate the client’s meal tray when the client stops eating.
ANS: D
This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.
DIF: Applying/Application REF: 936
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
ANS: D
The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.
DIF: Applying/Application REF: 938
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 client’s medication lists.
ANS: B
For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.
DIF: Applying/Application REF: 938
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 client’s vital signs.
c.
Notify the Rapid Response Team.
d.
Raise the head of the bed.
ANS: C
This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.
DIF: Applying/Application REF: 941
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.
ANS: B
Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.
DIF: Applying/Application REF: 942
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
ANS: C
Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.
DIF: Evaluating/Synthesis REF: 942
A client with a stroke has damage to Broca’s 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.
ANS: A
Damage to Broca’s area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. “Yes-or-no” questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up “words” often used by clients with sensory aphasia.
DIF: Applying/Application REF: 943
A client’s mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client’s 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
ANS: B
The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 – 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.
DIF: Analyzing/Analysis REF: 949
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.
ANS: A
These manifestations indicate Cushing’s syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.
DIF: Applying/Application REF: 952
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
ANS: A
A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.
DIF: Applying/Application REF: 952
A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client’s spouse is very frustrated, stating that the client’s 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.
ANS: A
Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn’t useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse’s concerns and feelings.
DIF: Applying/Application REF: 953
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)
ANS: D
A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.
DIF: Applying/Application REF: 953
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
ANS: B
In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.
DIF: Remembering/Knowledge REF: 954
