N476 FINAL CH18 – Flashcards

1. The patient's wife is upset by the preparations to take a patient suspected of having a suspected to the radiology department for computerized tomography (CT) of his brain. The nurse explains to her: a."We need to find out what part of his brain was involved in the stroke." b."This is the best way to determine whether his stroke was due to bleeding inside his brain or was the result of a clot." c."We can get images of the damage to his brain at this point and use them later to see if he has sustained more damage." d."This procedure will distinguish between a brain tumor and a stroke as the cause of your husband's problem."

2. The patient's son asks the nurse if his mother will have to have an arteriovenous malformation removed by surgery. He is concerned because her condition is so unstable that he doesn't think she can withstand the stress of an operation. The nurse explains: a."If we don't remove it surgically, she will die." b."There is a procedure called embolization that can be done to secure the lesion without surgery. When her condition is more stable, an operation might be considered if needed." c."The operation is necessary, even if it results in further brain damage and possible permanent changes in her neurological status." d."We can delay interventions until her condition is stable enough to risk surgery."

3. Knowing that the patient has been diagnosed with Guillain-Barré syndrome (GBS), the nurse anticipates that his paralysis will follow which course over the next few days to weeks? a.Descend to his lower extremities b.Subside and leave no residual effect c.Ascend d.Be more pronounced on his nondominant side

4. The patient's husband does not understand the diagnosis of ischemic stroke. To enhance his understanding the nurse explains: a."She has had a clot in her brain, and part of the tissue isn't getting any oxygen." b."Some bleeding occurred in her brain, and the pressure from the blood is causing her to have problems." c."The injuries she sustained in the auto accident caused bone to be pressed into her brain, which resulted in the changes that you see." d."An infection in her brain tissue is making it impossible for electrical impulses to travel in an efficient manner."

5. Knowing that a patient has hypoxemia and ischemia in his brain, the nurse anticipates which of the following? a.Cerebrovascular dilation b.Cardiovascular compensation c.Compensation of respiratory alkalosis d.Cerebral vasoconstriction

6. The nurse monitors the patient after rupture of a cerebral aneurysm. The careful surveillance is based on knowledge that the highest incidence of rebleeding after aneurysm rupture occurs within the first: a.hour after the initial bleed. b.24 hours after the initial bleed. c.48 hours after the first bleed. d.72 hours after the initial bleed.

7. Before initiating actions to induce mild hypothermia in the patient, the nurse explains to the family: a."This is to help keep the patient from getting a fever." b."This is to decrease the demands on the brain and to lower the increased pressure inside the patient's brain." c."This will increase the circulation to the brain and help it to function better." d."This will help sedate the patient so that he is not anxious and agitated."

8. Following admission to the intensive care unit (ICU), a patient with a severe skull fracture is noted to have pinkish grey matter near the site of the injury. The priority action for the nurse is to: a.monitor the appearance of the area hourly. b.notify the physician of the possibility of transcalvarial herniation. c.turn the patient to the nonaffected side. d.medicate the patient for pain.

9. The patient has preserved pupillary responses while comatose. The nurse recognizes this as a sign that the origin of the altered sensorium is most likely: a.brainstem injury. b.uncal herniation. c.metabolic state. d.subarachnoid hemorrhage.

10. The nurse's priority in eye care for the patient in a coma will be: a.keeping the lids closed to prevent fatigue of the tissue. b.having the patient perform range-of-motion exercises with the eyes. c.keeping the eyes moist to prevent corneal ulceration. d.removing accumulated secretions during bathing.

11. The patient's wife asks the nurse if her husband really had a stroke, because his symptoms resolved within 24 hours. The nurse explains: a."Sometimes the effects of strokes are very limited." b."This event is called a reversible ischemic neurologic deficit. It can be a warning that a stroke is going to occur within the next 48 hours." c."This was actually a transient ischemic attack, and it is a warning that a stroke may occur in the near future." d."The improvement is temporary. We expect to see neurological changes again in the next 24 hours."

12. An unconscious patient has a nursing diagnosis of decreased intracranial adaptive capacity related to failure of normal intracranial compensatory mechanisms. An appropriate nursing intervention for this problem is to: a.elevate the head of the bed 30 to 45 degrees. b.position the patient with the knees and hips flexed. c.cluster nursing interventions to provide uninterrupted periods of rest. d.encourage coughing and deep breathing to improve oxygenation.

13. One action that might help determine whether a coma is due to structural or metabolic causes is: a.reviewing the laboratory results for electrolyte levels. b.checking the patient's pupillary reaction to light. c.subjecting the patient to painful stimuli. d.observing the patient's waveforms on the electroencephalographic monitor.

14. The patient's husband asks the nurse what caused his wife to have a intracerebral hemorrhage. The nurse explains: a."It was most likely due to overexertion at work." b."Her high blood pressure is her biggest risk factor for intracerebral hemorrhage." c."Her having had a high cholesterol level for many years has caused this." d."It was probably because of a family history of cardiovascular disease."

15. A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important for the nurse to assess the patient's: a.ability to follow commands. b.visual fields. c.right-sided reflexes. d.emotional state.

16. A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for: a.intravenous heparin administration. b.transluminal angioplasty. c.surgical endarterectomy. d.tissue plasminogen activator (tPA) infusion.

17. On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following 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.

18. A patient with a stroke has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is: a.risk for impaired skin integrity related to immobility. b.disturbed sensory perception related to brain injury. c.risk for aspiration related to inability to protect airway. d.impaired physical mobility related to weakness.

19. 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.impaired verbal communication related to speech-language deficits. c.risk for injury related to denial of deficits and impulsiveness. d.ineffective coping related to depression and distress about disability.

20. The nurse observes that the patient has pupil dilation in the right eye, decreased consciousness, and changes in respiratory rate and rhythm. This is suggestive of: a.impending stroke. b.uncal herniation. c.Guillain-Barré syndrome d.cerebral vasoconstriction.

21. When caring for a patient in a coma what nursing intervention takes highest priority? a.Inserting an indwelling urinary catheter b.Maintaining a patent airway c.Putting a nasogastric (NG) tube in place d.Administering an enema daily

1. As the nurse caring for a patient in the ICU diagnosed with Guillain-Barré syndrome (GBS), you know to monitor for which of the following symptoms? (Select all that apply) a.Decreased coping b.Increased anxiety c.Progressive immobility d.Autonomic dysfunction e.Cranial nerve dysfunction f.Paresthesias g.Ineffective breathing pattern

2. To reduce metabolic demands in order to avoid increasing intracranial pressure, which of the following medications might be used? (Select all that apply) a.Neuromuscular blocking agents, such as vecuronium b.Benzodiazepines, such as lorazepam c.Sedative-hypnotics, such as propofol d.Opioid narcotics, such as fentanyl

3. A CT scan of the patient's brain shows that an expanding lesion in one hemisphere has shifted laterally and forced the cingulate gyrus to herniate. The nurse will observe the patient for what signs when monitoring the patient? (Select all that apply) a.There are no clinical manifestations of this condition. b.If the expansion of the lesion is not controlled, signs of uncal or central herniation will appear. c.The patient will have a severe headache on the side of the head where the lesion is located. d.The intracranial pressure on the side opposite the lesion will increase rapidly.