Ignatavicius Ch 45: Care of Critically Ill Patients with Neurologic Problems

Question 1

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)

Answer 1

b. Clopidogrel (Plavix)

This clients 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.

Question 2

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.

Answer 2

a. Most of these types of blood clots come from the heart.

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.

Question 3

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.

Answer 3

d. Rotate the clients meal tray when the client stops eating.

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.

Question 4

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

Answer 4

d. Time of symptom onset

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.

Question 5

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.

Answer 5

b. Ensure that informed consent is on the chart.

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.

Question 6

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.

Answer 6

c. Notify the Rapid Response Team.

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.

Question 7

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.

Answer 7

b. Inform the student that the docusate should be given.

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.

Question 8

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

Answer 8

c. Has clear lung sounds on auscultation

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.

Question 9

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.

Answer 9

a. Assess whether or not the client can write.

Damage to Brocas 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.

Question 10

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

Answer 10

b. Poor prognosis and cognitive function

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.

Question 11

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.

Answer 11

a. Call the provider or Rapid Response Team.

These manifestations indicate Cushings 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.

Question 12

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

Answer 12

a. Client with a Glasgow Coma Scale score that was 10 and is now is 8

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.

Question 13

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.

Answer 13

a. Explain that personality changes are common following brain injuries.

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 isnt 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 spouses concerns and feelings.

Question 14

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)

Answer 14

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

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.

Question 15

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

Answer 15

b. Client in a coma for 2 weeks from a motor vehicle crash

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.

Question 16

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)

Answer 16

b. Dexmedetomidine (Precedex)

Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

Question 17

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

Answer 17

a. I know I can take care of all these needs by myself.

This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word hopefully. Realizing the importance of respite care and support also is a realistic outlook.

Question 18

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.

Answer 18

d. Notify the provider of the findings immediately.

This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.

Question 19

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.

Answer 19

b. Assess the clients sodium level.

This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

Question 20

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.

Answer 20

a. The client will need near-total care.

This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the clients dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client.

Question 21

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.

Answer 21

a. Increased pressure from the abscess can cause seizures.

Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

Question 22

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.

Answer 22

b. Perform hand hygiene before client care.

All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.

Question 23

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

Answer 23

a. Balancing and recalibrating the device

This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the devices accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the devices accuracy is most important. The phlebostatic axis is not related to neurologic monitoring.

Question 24

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

Answer 24

a. A 27-year-old heavy cocaine user

Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.

Question 25

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.

Answer 25

a. Ask the client how long ago the clip was placed.

Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives.

Question 26

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

Answer 26

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

The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse

Question 27

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

Answer 27

c. Needs frequent re-orientation

This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.

Question 28

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.

Answer 28

a. Ambulate only with a gait belt.

Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

Question 29

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.

Answer 29

a. Attempt to find the family to sign a consent.

The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

Question 30

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

Answer 30

c. Risk for acquiring an infection

The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.

Question 31

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.

Answer 31

a. An aneurysm is a ballooning in a weakened part of an arterial wall.
c. Intracerebral hemorrhage is bleeding directly into the brain.
d. Reduced perfusion from vasospasm often makes stroke worse.

An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM

Question 32

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

Answer 32

a. Alcohol intake
c. High-fat diet
d. Obesity
e. Smoking

Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

Question 33

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.

Answer 33

b. Check and document oxygen saturation every 1 to 2 hours.
e. Position the client supine with the head in a neutral midline position.

The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

Question 34

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

Answer 34

a. Discharging the client on a statin medication
d. Providing and charting stroke education
e. Preventing venous thromboembolism

Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

Question 35

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.

Answer 35

a. A client with a moderate trauma may need hospitalization.
d. A client with a Glasgow Coma Scale score of 3 has severe TBI.
e. The terms mild TBI and concussion have similar meanings.

Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

Question 36

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.

Answer 36

a. Admission can overwhelm the coping mechanisms for older clients.
c. These clients are more susceptible to systemic and wound infections.
d. Other medical conditions can complicate treatment for these clients.

Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.

Question 37

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

Answer 37

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

The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.

Question 38

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

Answer 38

a. Client who exhibits extreme emotional lability
b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38
d. Client who has a past hospitalization for a suicide attempt
e. Client who is unable to walk or eat 3 weeks post-stroke

Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.

Question 39

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.

Answer 39

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.

All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

Question 40

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

Answer 40

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

After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.

Question 41

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

Answer 41

b. Is allergic to acetaminophen (Tylenol)
d. Lives alone and is new in town with no friends
e. Plans to have a beer and go to bed once home

Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.