Med-surg: Neurological Disorders Flashcards
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?
- Schedule for a STAT computed tomography (CT) scan of head.
= A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it has a hemorrhagic or ischemic accident and guide treatment.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?
- Paralysis of the right side of the body and ataxia.
= The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.
Which client would the nurse identify as being most at risk for experiencing a CVA?
- A 55-yea-old African American.
= African Americans have twice the rate of CVAs as Caucasians and men have a high incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which intervention should be included in the nursing care plan? (Select all that apply).
- Position the client to prevent should adduction.
- Encourage the client to move the affect side.
= Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture.
= The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
- Referring the client to an occupational therapist for evaluation.
= A collaborative intervention is an intervention in which another heal-care discipline - in this case, occupational therapy - is used in the care of the client.
The nurse an an unlicensed assistive personnel (UAP) are caring for a client with right sided paralysis. Which action by the UAP requires the nurse to intervene?
-The assistant places her hand under the client’s right axilla to help him move up in bed
This action is inappropriate and would require intervention by the nurse bc pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack. Which medication would the nurse anticipate being ordered for the client on discharge?
-An oral anticoagulant medication
The nurse would anticipate an oral anticoagulant, warfarin (coumadin) to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).
The client has been diagnosed with cerebrovascular accident (stroke) The clients wit is concerned about her husband’s generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
-Obtain a raised toilet seat for the client’s bathroom
Raising the toilet seat is modifying the home and addresses the client’s weakness in being able to sit down and get up with out straining muscles or requiring lifting assistance from the wife.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
-Powerlessness
Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize to verbalize needs, which in turn causes the client to have a lack of control and feel powerless.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
-A blood pressure of 220/120 mm Hg
Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.
The 85 year old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
-Complete a neurological assessment
= The nurse must complete a neurological assessment to help determine the cause of the headache to help determine the cause of the headache before taking and further action.
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the ICU nurse implement?
-Administer a stool softener BID
= The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore stool softeners would be appropriate.
