Practice Test Flashcards
A client had an embolic stroke and is having an echo cardiogram. The client asks why there is a “test on my heart”, how should the nurse respond?
“Most of these types of blood clots come from the heart”
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?
Rotate the clients meal tray when the client stops eating
A client had an embolectomy for an arteriovenous malformation. The client is now reporting a severe headache and has vomited. What action by the nurse takes priority?
Notify the Rapid Response Team
A clients mean arterial pressure is 60mm Hg and intracranial pressure is 20mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client?
Poor prognosis and cognitive function
A nurse is caring for four clients in the neurological intensive care unit. After receiving the hand off report, which client should the nurse see first?
Client with a Glasgow Coma Scale score that was 10 and is now 8
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
Client who has a temperature of 102F
A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer
Dexmedetomidine (Precedex). A sedative to manage agitation and ventilatory asynchrony.
A client who had a severe traumatic brain injury is being discharged home, spouse will be full time caregiver. What statement by spouse would lead the nurse to provide further education?
“I know I can take care of all these needs by myself”
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75mL/hr. What action by nurse is best?
Assess the clients sodium level
A client has a brain abscess and is receiving phenytoin (dilantin). The spouse questions the use of the drug and says the client does not have a seizure disorder. What response by nurse is best?
“Increased pressure from the abscess can cause seizures.”
A client has a subarachnoid bolt. What action by nurse is most important?
Balancing and re-calibrating the device.
A nurse is providing community screening for risk factors associated with stroke. Which client is highest risk?
A 27 year old heavy cocaine user
The nurse assesses a clients Glasgow Coma Scale score and determines it to be 12 (4 in each category). What care should the nurse anticipate?
Needs for frequent orientation
After a stroke, a client has ataxia. What intervention is most appropriate to include in plan of care?
Ambulate with a gate belt.
A client has a traumatic brain injury and positive halo sign. The client is in ICU, sedated and on ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?
Risk for acquiring an infection
