LA #10 (Neurological) Chapters 58, 59, 60, 61 Flashcards
A patient with a deep, large laceration of the left forearm, which has damaged nerve fibres as well as other tissue, asks the nurse to explain what the effect of the nerve damage will be. What is the best response to the patient?
a.
Nerve cells cannot regenerate, and the sensory and motor loss will be permanent.
b.
He will probably have return of normal motor and sensory function because peripheral nerve cells can regenerate.
c.
Only nerve fibres within the central nervous system are capable of regeneration, and the nerve loss he has distal to his injury will be permanent.
d.
There is a chance that some nervous function will return because peripheral nerve fibres can slowly regenerate if cell bodies have not been damaged.
D
In the peripheral nervous system, regeneration of injured nerve fibres is possible if the cell body is intact. The final result depends on the connections the axon sprouts make with end-organs and other nerves.
When interviewing an acutely confused patient who has a head injury, which question will provide the most useful information?
a.
“Have you ever been hospitalized for a neurological problem?”
b.
“Do you have any pain at the present time?”
c.
“What have you had to eat in the last 24 hours?”
d.
“Can you describe your usual pattern for coping with injury?”
B
The acutely confused patient will be able to state whether he currently has pain. The patient may not be able to provide accurate information about his history of hospitalization, 24-hour dietary recall, or usual coping patterns.
When the nurse administers a drug that increases the synaptic release of γ-aminobutyric acid (GABA), what is the effect the nurse would expect?
a.
Widespread increases in nervous system activity
b.
Suppression of nervous system activity
c.
Increased patient alertness and arousal
d.
Excitation of the affected postsynaptic neurons
B
GABA is a neurotransmitter that has inhibitory activity on action-potential generation and decreases nervous system activity.
For a patient who has a corticospinal tract lesion, the nurse should assess for which of the following?
a.
Extremity movement and strength
b.
Cranial nerve function
c.
Peripheral sensitivity to pain
d.
Level of consciousness
A
The corticospinal tract carries impulses from the cortex to the peripheral nerves that control voluntary muscle movement.
A patient has a lesion that affects lower motor neurons. During assessment of the patient’s lower extremities, what does the nurse expect to find?
a.
Spasticity
b.
Flaccidity
c.
Hyperreflexia
d.
Loss of sensation
B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles, and the nurse would assess flaccidity.
Which of the following assessment findings would the nurse expect when examining a patient with a lesion of the left posterior temporal lobe?
a.
Inability to reason or problem solve
b.
Loss of sensation on the left side of the body
c.
Inability to comprehend written or oral language
d.
Inability to voluntarily move the right side of the body
C
The posterior temporal lobe integrates the visual and auditory input for language comprehension.
What is the path of intervention with cranial nerve VI (abducens nerve) that is connected to the brain via the pons?
a.
Motor path
b.
Sensory path
c.
Sympathetic path
d.
Parasympathetic path
A
Cranial nerve VI (abducens nerve) that is connected to the brain via the pons has a motor path of intervention.
When obtaining a health history from a patient with a neurological problem, the nurse is likely to elicit the most valid response from the patient by asking the patient which of the following questions?
a.
“Do you ever have any nausea or dizziness?”
b.
“Does the pain radiate from your back into your legs?”
c.
“Do you have any sensations of pins and needles in your feet?”
d.
“Can you describe the sensations you are having in your chest?”
D
The most useful and valid information is obtained through the use of open-ended questions that allow the patient to describe symptoms.
When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily for which of the following reasons?
a.
To determine the patient’s motivation for self-care
b.
To include the patient in health care decisions
c.
To use the information given by the patient to guide care
d.
To assess the patient’s baseline cognitive abilities
D
The appropriateness of the patient’s response and the patient’s use of language will help the nurse assess the baseline cognitive abilities of the patient.
A 71-year-old patient reports a change in sleep patterns occurring over the past 2 to 3 years. Based on knowledge of the effects of aging on the reticular activating system, what would the nurse expect the patient to exhibit?
a.
Increased rapid-eye-movement sleep
b.
Longer cycles of sleep
c.
Increased sleep apnea
d.
Increased spontaneous awakening
D
Normal changes in the reticular activating system and autonomic nervous system lead to more spontaneous awakening and less sleep time in older adults.
To assess the functioning of the optic nerve (cranial nerve II), what should the nurse do?
a.
Apply a cotton wisp strand to the cornea.
b.
Perform a confrontational test for visual fields.
c.
Evaluate pupil response to light and accommodation.
d.
Ask the patient to follow a finger with the eyes as it is moved vertically, horizontally, and diagonally.
B
The optic nerve is responsible for visual fields and visual acuity.
Neurological testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (cranial nerve IX) and the vagus nerve (cranial nerve X). Based on these findings, what should the nurse plan to do?
a.
Insert an oral airway.
b.
Withhold oral fluid or foods.
c.
Provide highly seasoned foods.
d.
Apply artificial tears to protect the cornea.
B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration.
The following orders are received for a patient who is unconscious after a head injury caused by an automobile accident. Which one should the nurse question?
a.
Perform neurological checks every 15 minutes.
b.
Prepare the patient for lumbar puncture.
c.
Obtain X-ray films of the skull and spine.
d.
Do computed tomography scanning with and without contrast.
B
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture.
The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action by the new nurse indicates a need for further teaching about neurological assessment?
a.
Tests for light touch before testing for pain
b.
Has the patient close the eyes during testing
c.
Tells the patient, “You may feel a pinprick now.”
d.
Uses an irregular pattern to test for intact touch
C
When performing a sensory assessment, the nurse should not provide verbal or visual clues.
To prepare a patient who is to have a lumbar puncture performed for analysis of cerebrospinal fluid, what should the nurse inform him about?
a.
He will be given a mild sedative to help control muscle spasms.
b.
He should cough as soon as he feels the needle enter the spinal canal.
c.
He may be required to lie flat on his back for 24 hours following the test.
d.
He will be positioned on his side with his knees drawn to the chest and his head flexed to the chest.
D
For a lumbar puncture, the patient lies in the lateral recumbent position, with the knees drawn to the chest and the head flexed to the chest to separate the vertebrae.
When reviewing the results of a patient’s cerebrospinal fluid analysis obtained from a lumbar puncture, which of the following does the nurse identify as abnormal?
a.
pH 7.35
b.
White blood cell count 4 cells/microlitre (0.004 cells/L)
c.
Protein 0.30 g/L (30 mg/dL)
d.
Glucose 1.7 mmol/L (30 mg/dL)
D
The glucose level is low.
Which of the following is an age-related change in the nervous system?
a.
Increased efficiency of temperature-regulating mechanism
b.
Decreased size of ventricles in the brain
c.
Decrease in electrical activity
d.
Increase in deep-tendon reflexes
C
A normal age-related change is a decrease in electrical activity. The temperature-regulating mechanism is decreased in efficiency in aging. The size of the ventricles increases with age. The deep-tendon reflexes either remain the same or decrease in aging.
During the neurological assessment, the patient cooperates with the nurse’s directions to grip with the hands and to move the feet, but does not respond to the nurse’s questions. The nurse will suspect which of the following?
a.
A temporal lobe lesion
b.
Injury to the cerebellum
c.
A brainstem lesion
d.
Damage to the frontal lobe
D
Expressive speech is controlled by Broca’s area in the frontal lobe.
Which neurotransmitter is involved in emotions, moods, and regulating motor control?
a.
Serotonin
b.
Epinephrine
c.
Dopamine
d.
Substance P
C
Dopamine is involved in emotions, moods, and regulating motor activity. Serotonin is also involved with moods and emotions but has no relevance to regulating motor control.
Which internal structure arises from the basilar and two internal carotid arteries?
a.
Reticular formation
b.
Blood–brain barrier
c.
Circle of Willis
d.
Anterior communicating centre
C
The circle of Willis arises from the basilar and two internal carotid arteries.
Which area of the cerebrum would the nurses suspect is injured when the patient is unable to understand spoken words?
a.
Broca’s area
b.
Precentral gyrus
c.
Wernicke’s area
d.
Postcentral gyrus
C
The function of Wernicke’s area is to integrate auditory language, that is, understanding of spoken words.
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include
a.
prophylactic clipping of cerebral aneurysms.
b.
heparin via continuous intravenous infusion.
c.
oral administration of low dose aspirin therapy.
d.
therapy with tissue plasminogen activator (tPA).
C
The patient’s symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient’s symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
a.
The patient has dysphasia.
b.
The patient has atrial fibrillation.
c.
The patient states, “My symptoms started with a terrible headache.”
d.
The patient has a history of brief episodes of right-sided hemiplegia.
C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?
a.
Impulsive behavior
b.
Right-sided neglect
c.
Hyperactive left-sided reflexes
d.
Difficulty in understanding commands
D
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have
a.
dysphasia.
b.
confusion.
c.
visual deficits.
d.
poor judgment.
C
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient
a.
to monitor and record the blood pressure daily.
b.
to call the health care provider if stools are tarry.
c.
that Plavix will dissolve clots in the cerebral arteries.
d.
that Plavix will reduce cerebral artery plaque formation.
B
Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate?
a.
“The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.”
b.
“The diseased portion of the artery in the brain is removed and replaced with a synthetic graft.”
c.
“A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed.”
d.
“A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.”
A
In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, “The diseased portion of the artery in the brain is removed” describes an arterial graft procedure. The answer beginning, “A catheter with a deflated balloon is positioned at the narrow area” describes an angioplasty. The final response beginning, “A wire is threaded through the artery” describes the MERCI procedure.
When assessing a patient with a possible stroke, the nurse finds that the patient’s aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question?
a.
Infuse normal saline at 75 mL/hr.
b.
Keep head of bed elevated at least 30 degrees.
c.
Administer tissue plasminogen activator (tPA) per protocol.
d.
Titrate labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
D
Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for
a.
surgical endarterectomy.
b.
transluminal angioplasty.
c.
intravenous heparin administration.
d.
tissue plasminogen activator (tPA) infusion.
D
The patient’s history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to
a.
have the patient practice facial and tongue exercises.
b.
ask simple questions that the patient can answer with “yes” or “no.”
c.
develop a list of words that the patient can read and practice reciting.
d.
prevent embarrassing the patient by changing the subject if the patient does not respond.
B
Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no” response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of
a.
impaired physical mobility related to right hemiplegia.
b.
risk for injury related to denial of deficits and impulsiveness.
c.
impaired verbal communication related to speech-language deficits.
d.
ineffective coping related to depression and distress about disability.
B
Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?
a.
Apply an eye patch to the left eye.
b.
Approach the patient from the left side.
c.
Place objects needed for activities of daily living on the patient’s right side.
d.
Reassure the patient that the visual deficit will resolve as the stroke progresses.
C
During the acute period, the nurse should place objects on the patient’s unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care?
a.
Provide a wide variety of food choices.
b.
Provide oral care before and after meals.
c.
Assist the patient to eat with the left hand.
d.
Teach the patient the “chin-tuck” technique.
C
Because the nursing diagnosis indicates that the patient’s imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
a.
Applying intermittent pneumatic compression stockings
b.
Assisting to dangle on edge of bed and assess for dizziness
c.
Encouraging patient to cough and deep breathe every 4 hours
d.
Inserting an oropharyngeal airway to prevent airway obstruction
A
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then
a.
order a varied pureed diet.
b.
assess the patient’s appetite.
c.
assist the patient into a chair.
d.
offer the patient a sip of juice.
C
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patient’s wife insists on feeding and dressing him, telling the nurse, “I just don’t like to see him struggle.” Which nursing diagnosis is most appropriate for the patient?
a.
Situational low self-esteem related to increasing dependence on others
b.
Interrupted family processes related to effects of illness of a family member
c.
Disabled family coping related to inadequate understanding by patient’s spouse
d.
Impaired nutrition: less than body requirements related to hemiplegia and aphasia
C
The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care?
a.
Limit fluid intake to 1200 mL daily to reduce urine volume.
b.
Assist the patient onto the bedside commode every 2 hours.
c.
Perform intermittent catheterization after each voiding to check for residual urine.
d.
Use an external “condom” catheter to protect the skin and prevent embarrassment.
B
Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, “I don’t need the aspirin today. I don’t have any aches or pains.” Which action should the nurse take?
a.
Document that the aspirin was refused by the patient.
b.
Tell the patient that the aspirin is used to prevent aches.
c.
Explain that the aspirin is ordered to decrease stroke risk.
d.
Call the health care provider to clarify the medication order.
C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient’s refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
a.
alteplase (tPA).
b.
aspirin (Ecotrin).
c.
warfarin (Coumadin).
d.
nimodipine (Nimotop).
B
Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should
a.
use a calm voice to ask the patient to stop the crying behavior.
b.
explain to the family that depression is normal following a stroke.
c.
have the family members leave the patient alone for a few minutes.
d.
teach the family that emotional outbursts are common after strokes.
D
Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient’s outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient’s control and asking the patient to stop will lead to embarrassment.
The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?
a.
The patient has a daily glass of wine to relax.
b.
The patient is 25 pounds above the ideal weight.
c.
The patient works at a desk and relaxes by watching television.
d.
The patient’s blood pressure (BP) is usually about 180/90 mm Hg.
D
Hypertension is the single most important modifiable risk factor and this patient’s hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
a.
The patient’s speech is difficult to understand.
b.
The patient’s blood pressure is 144/90 mm Hg.
c.
The patient takes a diuretic because of a history of hypertension.
d.
The patient has atrial fibrillation and takes warfarin (Coumadin).
D
The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient’s care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?
a.
Electrocardiogram (ECG)
b.
Complete blood count (CBC)
c.
Chest radiograph (Chest x-ray)
d.
Noncontrast computed tomography (CT) scan
D
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient?
a.
Impaired physical mobility related to weakness
b.
Disturbed sensory perception related to brain injury
c.
Risk for impaired skin integrity related to immobility
d.
Risk for aspiration related to inability to protect airway
D
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?
a.
The patient’s blood pressure is 90/50 mm Hg.
b.
The patient complains about having a stiff neck.
c.
The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
d.
The patient complains of an ongoing severe headache.
A
To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN?
a.
Assess the patient’s gag and cough reflexes.
b.
Determine when the stroke symptoms began.
c.
Administer the prescribed clopidogrel (Plavix).
d.
Infuse the prescribed IV metoprolol (Lopressor).
C
Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
a.
A patient with right-sided weakness who has an infusion of tPA prescribed
b.
A patient who has atrial fibrillation and a new order for warfarin (Coumadin)
c.
A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
d.
A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
A
tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.
The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
a.
The pulse rate is 104 beats/min.
b.
The patient has difficulty talking.
c.
The blood pressure is 142/88 mm Hg.
d.
There are fine crackles at the lung bases.
B
Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.
A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
a.
Check the respiratory rate.
b.
Monitor the blood pressure.
c.
Send the patient for a CT scan.
d.
Obtain the Glasgow Coma Scale score.
A
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________
a. Obtain CT scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation >95%.
d. Use National Institute of Health Stroke Scale to assess patient.
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
A patient has a systemic blood pressure of 120/60 mm Hg and an intracranial pressure (ICP) of 24 mm Hg. What does the nurse determine that the cerebral perfusion pressure (CPP) of this patient indicates?
a.
High blood flow to the brain
b.
Normal ICP
c.
Impaired blood flow to the brain
d.
Adequate autoregulation of cerebral blood flow
C
The patient’s CPP is 56 mm Hg, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death.
ICP monitoring is instituted for a patient with a head injury. The patient’s arterial blood pressure is 92/50 mm Hg, and her ICP is 18 mm Hg. Which nursing action is most appropriate?
a.
Document and continue to monitor the parameters.
b.
Elevate the head of the patient’s bed.
c.
Notify the physician about the assessments.
d.
Check the patient’s pupillary response to light.
C
The patient’s CPP is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial blood pressure, so the most appropriate action is to contact the physician.
Patient manifestations of a headache, CSF leakage, and cranial nerve deficit are signs of which one of the following indications for cranial surgery?
a.
Brain tumour
b.
Skull fracture
c.
Hydrocephalus
d.
Intracranial infection
B
Patient manifestations of a headache, CSF leakage, and cranial nerve deficit indicate a skull fracture, which requires cranial surgery.
A patient with a serum sodium level of 115 mmol/L has a decreasing level of consciousness (LOC) and complains of a headache. Which of the following orders should be the priority?
a.
Administer acetaminophen (Tylenol) 650 mg orally.
b.
Administer 5% hypertonic saline intravenously.
c.
Draw blood for arterial blood gases (ABGs).
d.
Send the patient to the radiology department for computed tomography of the head.
B
The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse’s first action should be to correct the low sodium level.
The wife of a patient who is in a coma is optimistic about her husband’s recovery because he opens his eyes and appears to be awake. What is the most appropriate response to the wife’s comment?
a.
“Your husband’s behaviour is only a reflex and does not really show improvement in his condition.”
b.
“Sleep–wake cycles are encouraging signs of recovery, and you should be optimistic about your husband’s condition.”
c.
“You are right to be optimistic. When patients begin to recover from a coma, the first behaviours seen are those of wakefulness.”
d.
“Your husband may show sleep–wake patterns if the part of the brain responsible for arousal is not injured, but these patterns do not reflect activity of the higher brain centres.”
D
Arousal is controlled by the reticular activating system in the brainstem and will allow the patient to maintain wakefulness even though the damage to the cerebral cortex is severe.
When assessing a patient with a head injury, what will the nurse recognize as an early indication of increased ICP?
a.
Vomiting
b.
Headache
c.
Change in the LOC
d.
Sluggish pupillary response to light
C
LOC is the most sensitive indicator of the patient’s neurological status and possible changes in ICP.
A patient is admitted to the hospital with a head injury resulting from an automobile accident. On admission, the patient’s vital signs are temperature 37°C, blood pressure 128/68 mm Hg, pulse 110 beats/min, and respiration 26 breaths/min. One hour after admission, which of the following vital signs does the nurse note indicates the presence of Cushing’s triad?
a.
Blood pressure 140/60 mm Hg, pulse 60 beats/min, respiration 14 breaths/min
b.
Blood pressure 130/72 mm Hg, pulse 90 beats/min, respiration 24 breaths/min
c.
Blood pressure 148/78 mm Hg, pulse 112 beats/min, respiration 28 breaths/min
d.
Blood pressure 110/70 mm Hg, pulse 120 beats/min, respiration 30 breaths/min
A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce the ICP.
Which of the following assessment data of the oculomotor nerve make the nurse suspicious of a possible supratentorial herniation and compression of the brainstem?
a.
Absent corneal reflexes
b.
Development of nystagmus
c.
Right pupil does not react to light
d.
Left pupil is 10 mm in size
C
A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation.
When the nurse applies a painful stimulus to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. How should the nurse interpret this finding?
a.
Decorticate posturing indicating an interruption of voluntary motor tracts
b.
Decerebrate posturing indicating an interruption of voluntary motor tracts
c.
Decorticate posturing indicating a disruption of motor fibres in the midbrain and brainstem
d.
Decerebrate posturing indicating a disruption of motor fibres in the midbrain and brainstem
D
With decerebrate posturing, the arms are stiffly extended, adducted, and hyperpronated.
When a patient’s ICP is being monitored with an intraventricular catheter, what is a priority nursing intervention?
a.
Maintaining strict aseptic technique to prevent infection
b.
Maintaining the patient’s head in a fixed position
c.
Continuous monitoring of the ICP waveform
d.
Removing CSF to keep pressure at normal levels
A
Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; therefore, a priority intervention would be strict aseptic technique at all times.
The charge nurse observes a new graduate nurse who is caring for a patient who has had a craniotomy for a brain tumour. Which action by the new graduate requires the charge nurse to intervene and provide additional teaching?
a.
The new nurse has the patient breathe deeply and cough.
b.
The new nurse assesses neurological status every hour.
c.
The new nurse elevates the head of the bed to 30 degrees.
d.
The new nurse administers an analgesic before turning the patient.
A
Coughing can increase ICP and is generally discouraged in patients at risk for increased ICP.
A patient is brought to the emergency department by ambulance after she was found unconscious on the bathroom floor by her husband. In admitting the patient, what is it most important for the nurse to assess first?
a.
Health history
b.
Airway patency
c.
Neurological status
d.
Status of bodily functions
B
Airway patency and breathing are the most vital functions and should be assessed first.
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. Which of the following should the nurse do to evaluate the effectiveness of the therapy?
a.
Monitor oxygen saturation.
b.
Check ABGs.
c.
Monitor ICP.
d.
Assess the patient’s breath sounds.
C
The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective.
The physician prescribes intravenous (IV) mannitol (Osmitrol) for an unconscious patient. What would the nurse expect the therapeutic effect of this drug to result in?
a.
Decreased seizure activity
b.
Decreased cerebral edema
c.
Decreased cerebral metabolism
d.
Decreased cerebral inflammation
B
Mannitol is an osmotic diuretic and will reduce cerebral edema and ICP.
A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D5W) at 50 mL/hour for 4 days. The nurse will anticipate the need for which of the following?
a.
Continue the D5W to provide the needed glucose for brain function.
b.
Decrease the rate of IV infusion to avoid increasing cerebral edema.
c.
Insert an enteral feeding tube to provide nutritional replacement.
d.
Administer IV 5% albumin to increase serum protein levels.
C
The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide nutrients for brain function and for healing and immune function. D5W does not provide adequate nutrition to meet patient needs and can lead to lower serum osmolarity and cerebral edema.
When assessing a patient with a head injury, which assessment information is of most concern to the nurse?
a.
The blood pressure increases from 120/54 to 136/62 mm Hg.
b.
The patient is more difficult to arouse.
c.
The patient complains of a headache at pain level 5 of a 10-point scale.
d.
The patient’s apical pulse is slightly irregular.
B
The change in the LOC is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications.
A patient with a head injury opens his eyes when his name is called, curses when he is stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. How should the nurse record the patient’s Glasgow Coma Scale score?
a.
9
b.
11
c.
13
d.
15
B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system integrative function for a patient who has post-traumatic brain swelling based on which of the following findings?
a.
Apneustic breathing
b.
Crackles on inspiration
c.
Glasgow Coma Scale score less than 8
d.
CPP less than 60 mm Hg
A
Apneustic breathing is caused by loss of central nervous system integration in the pons and is not effective in maximizing gas exchange.
A woman is admitted unconscious to the emergency department after striking her head on a boulder while hiking. Her husband and three teenaged children will not leave her side and constantly ask about the treatment being given. What is the best approach to the patient’s family?
a.
Call the family’s pastor or spiritual advisor to support them while initial care is given.
b.
Refer the family members to the hospital counselling service to deal with their anxiety.
c.
Allow the family to stay with the patient, and explain all procedures thoroughly to them.
d.
Ask the family to wait in the waiting room until the initial assessment can be completed and care can be started.
C
The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures.
An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. What is an appropriate nursing intervention for this problem?
a.
Elevate the head of the bed 30 degrees.
b.
Provide a position of comfort with the knees and hips flexed.
c.
Cluster nursing interventions to provide uninterrupted periods of rest.
d.
Teach the patient to cough and breathe deeply to prevent the necessity for suctioning.
A
The patient with increased ICP should be maintained in the head-up position to help reduce ICP.
The nurse notes that a patient with a head injury has a clear nasal drainage. What is the most appropriate nursing action for this finding?
a.
Obtain a specimen of the fluid for culture and sensitivity.
b.
Check the nasal drainage for glucose with a Dextrostix or Tes-Tape.
c.
Take the patient’s temperature to determine whether a fever is present.
d.
Instruct the patient to blow his nose and then check the nares for inflammation.
B
If the drainage is CSF leakage from a dural tear, glucose will be present.
A patient was brought to the emergency department when he became faint and disoriented after being hit in the head with a baseball bat during a company picnic. On admission, he has a headache and cannot remember being hit, but he has no other signs of neurological deficit. What would the nurse expect treatment for the patient to include?
a.
Diagnostic testing with magnetic resonance imaging
b.
Hospitalization for observation for 24 hours
c.
Discharge with observation and monitoring instructions
d.
Administration of a narcotic for the headache, followed by observation for several hours
C
A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates.
A victim of an automobile accident was found unconscious at the scene of the accident but regained consciousness during transport to the hospital. Shortly after admission, her Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse plans care for the patient based on the expectation that which of the following treatments will be included?
a.
Immediate craniotomy
b.
Administration of IV furosemide (Lasix)
c.
Administration of IV corticosteroids
d.
Endotracheal intubation with mechanical ventilation
A
As the Glasgow Coma Scale indicates a severe head injury, the principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation; therefore, an immediate craniotomy is expected.
The nurse notes clear drainage from the nose of a patient with a frontal skull fracture and recognizes that which of the following interventions is absolutely contraindicated for this patient?
a.
Lying flat
b.
Eating solid food
c.
Inserting a nasogastric tube
d.
Cold packs for facial bruising
C
Rhinorrhea may indicate a dural tear with CSF leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis.
In planning long-term care for the patient following brain trauma, what is the primary reason the nurse includes teaching and support for the family?
a.
Patients will always have some residual deficits of the brain damage.
b.
Most patients experience seizure disorders in the weeks or even years following head injury.
c.
Families become dysfunctional and unable to cope with the role reversals required during convalescence.
d.
Patients with head injuries with unconsciousness often have changes in personality with loss of concentration and memory processing.
D
Changes in personality, concentration, and memory are common after severe head injury and require anticipatory guidance for the patient and family.
During the assessment of a patient who has a tumour of the left frontal lobe, what would the nurse expect to find?
a.
Speech disturbances
b.
Ataxic gait and vertigo
c.
Personality and judgement changes
d.
Papilledema and vision disturbances
C
The frontal lobes control intellectual activities such as judgement.
A patient with increasing headaches who is having diagnostic testing for a brain tumour asks the nurse what type of treatment will be used if a tumour is discovered. Which response is most appropriate?
a.
“If the tumour is benign, treatment may not be necessary.”
b.
“Therapy to remove or reduce the tumour size will be recommended.”
c.
“Surgery will initially be used to reduce or remove the tumour.”
d.
“Chemotherapy is used to shrink the tumour, followed by craniotomy.”
B
Treatment is designed to reduce tumour size or remove the tumour.
Which one of the following types of cranial surgery is done to remove a bone flap?
a.
Burr hole
b.
Craniotomy
c.
Craniectomy
d.
Cranioplasty
C
A craniectomy is an excision into the cranium to cut away a bone flap.
Which one of the following can be caused by bacteria, fungi, a parasite, or a virus?
a.
Meningitis
b.
Brain abscess
c.
Encephalitis
d.
Brain hemorrhage
C
Encephalitis can be caused by bacteria, fungi, a parasite, or a virus.
Following a craniotomy with a craniectomy and left anterior fossa incision, the patient has a nursing diagnosis of ineffective protection related to decreased level of consciousness and weakness. What does an appropriate nursing intervention for the patient include?
a.
Assessing for changes in motor ability daily
b.
Performing range-of-motion exercises every 4 hours
c.
Turning and repositioning the patient side to side every 4 hours
d.
Eliminating extraneous noise to prevent sensory overload
B
Range-of-motion exercises will help prevent the complications of immobility.
Direct extension from a local infection in which of the following locations can be a primary cause of a brain abscess?
a.
Eye
b.
Ear
c.
Lung
d.
Endocardium
B
Direct extension from a local ear infection can be a primary cause of a brain abscess; others include tooth, mastoid, or sinus infection.
Rabies manifests as which of the following?
a.
Bacterial meningitis
b.
Viral encephalitis
c.
Viral meningitis
d.
Bacterial encephalitis
B
The cause of rabies is an RNA virus that produces an acute, progressive viral encephalitis.
A patient admitted with bacterial meningitis and a temperature of 38.9°C has orders for all of these collaborative interventions. Which one should the nurse accomplish first?
a.
IV ceftizoxime (Cefizox) 1 g now and every 6 hours
b.
IV dexamethasone (Decadron) 4 mg now
c.
Hypothermia blanket to keep the temperature less than 38.7°C
d.
Nasopharyngeal swab for culture and sensitivity
D
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started.
The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?
a.
Emphasize the importance of handwashing to prevent the spread of infection.
b.
Immunize adolescents and college freshmen against Neisseria meningitidis.
c.
Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
d.
Encourage adolescents and young adults to avoid crowded areas in the winter.
B
The N. meningitidis vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college/university freshmen.
After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says,
a.
“I will take the (Topamax) as soon as any headaches start.”
b.
“I should avoid taking aspirin and sumatriptan (Imitrex) at the same time.”
c.
“I will try to lie down someplace dark and quiet when the headaches begin.”
d.
“A glass of wine might help me relax and prevent headaches from developing.”
C
It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal anti-inflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
When a patient is experiencing a cluster headache, the nurse will plan to assess for
a.
nuchal rigidity.
b.
projectile vomiting.
c.
unilateral eyelid swelling.
d.
throbbing, bilateral facial pain.
C
Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
A patient has a tonic-clonic seizure while the nurse is in the patient’s room. Which action should the nurse take?
a.
Insert an oral airway during the seizure to maintain a patent airway.
b.
Restrain the patient’s arms and legs to prevent injury during the seizure.
c.
Avoid touching the patient to prevent further nervous system stimulation.
d.
Time and observe and record the details of the seizure and postictal state.
D
Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, “I cannot teach anymore, it will be too upsetting if I have a seizure at work.” Which response by the nurse is best?
a.
“You may want to contact the Epilepsy Foundation for assistance.”
b.
“You might benefit from some psychologic counseling at this time.”
c.
“The Department of Vocational Rehabilitation can help with work retraining.”
d.
“Most patients with epilepsy are well controlled with antiseizure medications.”
D
The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the patient seizures persist after treatment with antiseizure medications is implemented.
