Stroke, Seizure and Neuro Exam – Flashcards
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In a patient with a disease that affects the myelin sheath of the nerves such as multiple sclerosis, the glial cells affected are the a.microglia b.astrocytes c.ependymal cells d.oligodendrocytes
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D
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Drugs or diseases the impair the function of the extrapyramidal system may cause loss of a. sensations of pain and temperature b. regulation of the autonomic nervous system c. integration of somatic and special sensory inputs d. automatic movements associated with skeletal muscle activity
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D
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An obstruction of the anterior cerebral arteries will affect functions of a. visual imaging b. balance and coordination c. judgment, insight, and reasoning d. visual and auditory integration for language comprehension
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C
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Paralysis of lateral gaze indicates a lesion of cranial nerve a. II b. III c. IV d.VI
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D
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A result of stimulation of the parasympathetic nervous system is (select all that apply) a. constriction of the bronchi b. dilation of skin blood vessels c. increased secretion of insulin d. increased blood glucose levels e. relation of the urinary sphincters
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A,B,C,E
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Assessment of muscle strength of older adults cannot be compared with that of younger adults because a. stroke is more common in older adults b. nutritional status is better in young adults c. most young people exercise more than older people d. aging leads to a decrease in muscle bulk and strength
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D
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Data regarding mobility, strength, coordination, and activity tolerance are important for the nurse to obtain because a. many neurologic diseases affect one or more of these areas b. patients are less able to identify other neurologic impairments c. these are the first functions to be affected by neurologic disease d. aspects of movement are the most important function of the nervous system
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A
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During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for a. position sense b. patellar reflexes c. temperature perception d. heel-to-shin movements
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C
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A patient's eyes jerk while the patient looks to the left. You will record this finding as a.nystagmus b. CN VI palsy c. oculocephalia d. ophthalmic dyskinesia
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A
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The nurse is caring for a patient with peripheral neuropathy who is going to have EMG studies tomorrow morning. The nurse should a. ensure the patient has an empty bladder b. instruct the patient that there is no risk of electric shock c. ensure the patient has no metallic jewelry or metal fragments d. instruct the patient that she or he may experience pain during the study
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B
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Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter b. altering the endothelial lining of cerebral capillaries c. leaking molecules from the intracellular fluid to the capillaries
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B
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A patient with intracranial pressure monitoring has pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of cerebrospinal fluid c. the loss of autoregulatory control of intracranial pressure. d. a normal balance between brain tissue, blood, and cerebrospinal fluid
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D
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The nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat b. elevate the head of the bed to 30 degrees c. maintain patient of the left side with the head supported on a pillow d. use a continuous rotation bed to continuously change patient position
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B
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The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery b. has focal symptoms of brain damage with no recollection of a head injury c. develops decreased level of consciousness and a headache within 48 hours of a head injury d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness
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C
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During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway b. presence of a neck injury c. neurologic status with the glasgow coma scale d. cerebrospinal fluid leakage from the ears or nose
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A
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A patient is suspected of having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe b. parietal lobe c. occipital lobe d. temporal lobe
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A
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Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior b. using diversion techniques to keep the patient stimulated and motivated c. assisting and supporting the family in understanding any changes in behavior d. limiting self-care activities until the patient has regained maximum physical functioning e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs
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C,E
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The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a headache of 10 on a zero to ten scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis
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C
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A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain b. controlling fever with prescribed drugs and cooling techniques c. keeping the room darkened and quite to minimize environmental stimulation d. maintaining the patient on strict bed rest with the head of the bed slightly elevated
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B
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Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a. an obese 45 year old native american b. a 35 year old asian american woman who smokes c. a 32 year old white woman taking oral contraceptives d. a 65 years old African American man with hypertension
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D
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The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output b. oxygen content of the blood c. degree of collateral circulation d. level of carbon dioxide in the blood
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C
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Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance b. a history of hypertension c. presence of motor weakness d. sudden onset of severe headache
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D
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A patient with right sided hemiplegia and asphasia resulting from a stroke most likely has involvement of the a. brainstem b. vertebral artery c. left middle cerebral artery d. right middle cerebral artery
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C
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The nurse explains to the patient with a stroke who is scheduled for aniography that this test is used to determine a. presence of increased ICP b. site and size of the infarction c. patency of the cerebral blood vessels d. presence of blood in the cerebrospinal fluid
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C
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A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decreased cerebral edema b. reduce the brain damage that occurs during a stroke in evolution c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation
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C
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For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal b. time at which stroke symptoms first appeared c. patient's hypertension history and management d. family history of stroke and other cardiovascular diseases
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B
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Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake b. keeping a urinal in place at all times c. assisting the patient to stand to void d. catherizing the patient every four hours
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C
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Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression b. disassociation c. intellectualization d. sleep disturbances e. denial of the severity of the stroke
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A,D,E
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A 50 year old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his eye seems to swell and get teary when these headaches occur. Based on this history you suspect that he has a. cluster headaches b. tension headaches c. migraine headaches d. medication overuse headaches
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A
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A 65 year old woman was just diagnosed with parkinson's disease. The priority nursing intervention is a. searching the internet for educational videos b. evaluating the home for environmental safety c. promoting physical exercise and a well balanced diet d. designing an exercise program to strengthen and stretch specific muscles
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C
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The nurse assesses that a n 87 year old woman with alzheimers disease is continually rubbing, flexing, and kicking out her legs throughout the day. The night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to a. ask the physician for a daytime sedative for the patient b. request soft restraints to prevent her from falling out of her bed c. ask the physician for a nighttime sleep medication for the patient d. assess the patient more closely, suspecting a disorder such as restless leg syndrome
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D
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Social effects of a chronic neurologic disease include (select all that apply) a. divorce b. job loss c. depression d. role changes e. loss of self esteem
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A,B,C,D,E
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One major goal of treatment for a patient with huntingtons disease is a. disease cure b. symptomatic relief c. maintaining employment d. improving muscle strength
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B
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During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) a. inspect all aspects of the mouth and teeth b. assess the gag reflex and respiratory rate and depth c. lightly palpate the affected side of the face for edema d. test for temperature and sensation perception n the face e. ask the patient to describe factors that initiate an episode
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A,D,E
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During routine assessment of a patient with guillain-barre syndrome, the nurse finds the patient to be short of breath. The patient's respiratory distress is caused by a. elevated protein levels in the CSF b. immobility resulting from ascending paralysis c. degeneration of motor neurons in the brainstem and spinal cord d. paralysis ascending to the nerves that stimulate the thoracic area
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D
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The increased risk for falls in the older adult is most likely due to a. changes in balance b. decreased in bone mass c. loss of ligament elasticity d. erosion of articular cartilage
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A
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Management of the patient with bacterial meningitis includes: 1.Administering antibiotics immediately after collection of specimens for culture. 2.Waiting for results of a CSF culture to identify an organism before initiating treatment. 3.Providing symptomatic and supportive treatment because drug therapy is not effective in treatment. 4.Obtaining skull x-rays and CT scans to determine the extent of the disease before treatment is started.
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Answer: 1 Rationale: Bacterial meningitis is a medical emergency. Rapid diagnosis based on history and physical examination is crucial because the patient is usually in a critical state when health care is sought. When meningitis is suspected, antibiotic therapy is instituted after collection of specimens for cultures, even before the diagnosis is confirmed.
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A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the patient: 1.Is ready for aggressive rehabilitation. 2.Will show gradual improvement of the initial neurologic deficits. 3.May show signs of deteriorating neurologic function as cerebral edema increases. 4.Should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits.
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Answer: 3 Rationale: Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase
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While performing health screening at a health fair, the nurse identifies which of the following individuals at greatest risk for experiencing a stroke? 1.A 46-year-old white female with hypertension and oral contraceptive use for 10 years. 2.A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dL. 3.A 42-year-old African American female with diabetes mellitus who has smoked for 30 years. 4.A 62-year-old African American male with hypertension who is 35 pounds overweight.
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Answer: 4 Rationale: Option 4: This individual has five risk factors: age, African American, male, hypertension, and overweight.
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A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take first? 1. Check the patient's gag reflex. 2. Request a soft diet with no liquids. 3. Place the patient in high-Fowler's position. 4. Test the patient's ability to swallow with a small amount of water.
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Answer: 1 Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.
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Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is 1.An obese 45-year-old Native American 2.A 35-year-old Asian American woman who smokes 3.A 32-year-old white woman taking oral contraceptives 4.A 65-year-old African American man with HTN
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Answer: 4 Rationale: Stroke risk increases with age, doubling each decade after 55-years-old. 2/3 of all strokes occur in ages greater than 65. African American men are 4 times more likely....
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A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to 1.Decrease cerebral edema 2.Reduce the brain damage that occurs during a stroke in evolution 3.Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow 4.Provide a circulatory bypass around thrombotic plaques obstructing cranial circulation
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Answer: 3 Rationale: This is completed to prevent impending cerebral infarction. Atherosclerotic plaques are removed.
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The nurse is called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, the nurse should: 1.Turn the patient to the side. 2.Start oxygen by mask at 6 L/min. 3.Restrain the patient's arms and legs to prevent injury. 4.Record the time sequence of the patient's movements and responses as they occur
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Answer: 1 Rationale: During the seizure, the nurse should maintain a patent airway, protect the patient's head, turn the patient to the side, loosen constrictive clothing, and ease the patient to the floor, if seated. The patient should not be restrained, and no objects should be placed in the mouth. After the seizure, the patient may require repositioning to open and maintain the airway, suctioning, and oxygen. When a seizure occurs, the nurse should carefully observe and record details of the event because diagnosis and subsequent treatment often rest solely on the seizure description.
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Interferon β-1b (Betaseron) has been prescribed for a young woman who has been diagnosed with relapsing-remitting multiple sclerosis. The nurse determines that additional teaching about the drug is needed when the patient says, 1."I will need to rotate injection sites with each dose I inject." 2."I should report any depression or suicidal thoughts that develop." 3."I should avoid direct sunlight and use sunscreen and protective clothing when out of doors." 4."Because this drug is a corticosteroid, I should reduce my sodium intake to prevent edema."
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Answer: 4 Rationale: Interferon β-1b (Betaseron) is an immunomodulator drug (and not a corticosteroid). The drug is given subcutaneously every other day. Patient teaching should include the following: rotate injection sites with each dose; assess for depression and suicidal ideation; wear sunscreen and protective clothing while exposed to the sun; and know that flu-like symptoms are common following initiation of therapy.
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An appropriate nursing diagnosis for a patient with advanced Parkinson's disease is 1.Risk for injury related to limited vision. 2.Risk for aspiration related to impaired swallowing. 3.Urge incontinence related to effects of drug therapy. 4.Ineffective breathing pattern related to diaphragm fatigue.
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Answer: 2 Rationale: As swallowing becomes more difficult (dysphagia), malnutrition or aspiration may result
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When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. The nurse would document this as A) a. Ataxia. B) b. Apraxia. C) c. Anisocoria. D) d. Anosognosia.
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A
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When assessing the accessory nerve, the nurse would A) a. Assess the gag reflex by stroking the posterior pharynx. B) b. Ask the patient to shrug the shoulders against resistance. C) c. Ask the patient to push the tongue to either side against resistance. D) d. Have the patient say "ah" while visualizing elevation of soft palate.
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B
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When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm demonstrated by downward drifting of the arm. The nurse would most accurately document this finding as A) a. Athetosis. B) b. Hypotonia. C) c. Hemiparesis. D) d. Pronator drift.
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D Downward drifting of the arm or pronation of the palm is identified as a pronator drift. Hemiparesis is weakness of one side of the body; hypotonia defines a flaccid muscle tone; and athetosis is a slow, writhing, involuntary movement of the extremities.
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A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which of the following assessments should the nurse complete prior to this diagnostic study? A) a. Assess the patient's immunization history. B) b. Screen the patient for any metal parts or a pacemaker. C) c. Assess the patient for allergies to shellfish, iodine, or dyes. D) d. Assess the patient's need for tranquilizers or antiseizure medications.
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C
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A patient who has a neurologic disease that affects the pyramidal tract is likely to manifest which of the following signs? A) a. Impaired muscle movement B) b. Decreased deep tendon reflexes C) c. Decreased level of consciousness D) d. Impaired sensation of touch, pain, and temperature
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A Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement. Diseases affecting the pyramidal tract do not result in changes in LOC, impaired reflexes, or decreased sensation.
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How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? A) a. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. B) b. Ask the patient to maintain balance while standing with his or her feet together and eyes closed. C) c. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. D) d. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.
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B
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A patient with a suspected closed head injury has bloody nasal drainage. The nurse suspects that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following? A) a. A halo sign on the nasal drip pad B) b. Decreased blood pressure and urinary output C) c. A positive reading for glucose on a Test-tape strip D) d. Clear nasal drainage along with the bloody discharge
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A When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose
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The nurse assesses a patient for signs of meningeal irritation and observes her for nuchal rigidity. Which of the following indicates the presence of this sign of meningeal irritation? A) a. Tonic spasms of the legs B) b. Curling in a fetal position C) c. Arching of the neck and back D) d. Resistance to flexion of the neck
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D
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The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which of the following changes in vital signs would the nurse interpret as a manifestation of increased intracranial pressure? A) a. Tachypnea B) b. Bradycardia C) c. Hypotension D) d. Narrowing pulse pressure
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B Changes in vital signs indicative of increased intracranial pressure are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.
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The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic vital signs. Which of the following assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)? A) a. Judgment B) b. Eye opening C) c. Abstract reasoning D) d. Best verbal response E) e. Best motor response F) f. Cranial nerve function
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B,D,E
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Which of the following nursing actions should be implemented in the care of a patient who is experiencing increased intracranial pressure (ICP)? A) a. Monitor fluid and electrolyte status astutely. B) b. Position the patient in a high Fowler's position. C) c. Administer vasoconstrictors to maintain cerebral perfusion. D) d. Maintain physical restraints to prevent episodes of agitation.
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A
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Which of the following modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A) a. Hypertension B) b. Hyperlipidemia C) c. Alcohol consumption D) d. Oral contraceptive use
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A
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The nurse would expect to find which of the following clinical manifestations in a patient admitted with a left-brain stroke? A) a. Impulsivity B) b. Impaired speech C) c. Left-side neglect D) d. Short attention span
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B Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language aphasias, impaired right/left discrimination, and slow and cautious performance. The other options are all manifestations of right-sided brain damage.
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The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which of the following medications might the nurse expect to provide discharge instructions (select all that apply)? A) a. Clopidogrel (Plavix) B) b. Enoxaparin (Lovenox) C) c. Dipyridamole (Persantine) D) d. Enteric-coated aspirin (Ecotrin) E) e. Tissue plasminogen activator (tPA)
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A,C,D
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Which of the following nursing interventions is most appropriate when communicating with a patient suffering from aphasia poststroke? A) a. Present several thoughts at once so that the patient can connect the ideas. B) b. Ask open-ended questions to provide the patient the opportunity to speak. C) c. Use simple, short sentences accompanied by visual cues to enhance comprehension. D) d. Finish the patient's sentences so as to minimize frustration associated with slow speech.
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C
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Computed tomography of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. Which of the following is a nursing priority intervention in the emergency department? A) a. Maintenance of the patient's airway B) b. Positioning to promote cerebral perfusion C) c. Control of fluid and electrolyte imbalances D) d. Administration of tissue plasminogen activator (tPA)
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A
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A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 2 weeks earlier. How should the nurse best promote the health of the patient's integumentary system? A) a. Position the patient on her weak side the majority of the time. B) b. Alternate the patient's positioning between supine and side-lying. C) c. Avoid the use of pillows in order to promote independence in positioning. D) d. Establish a schedule for the massage of areas where skin breakdown emerges.
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B
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Which of the following sensory-perceptual deficits is associated with left-brain stroke (right hemiplegia)? A) a. Overestimation of physical abilities B) b. Difficulty judging position and distance C) c. Slow and possibly fearful performance of tasks D) d. Impulsivity and impatience at performing tasks
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C Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke.
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The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for which of the following? A) a. An aura B) b. Nystagmus or confusion C) c. Abdominal pain or cramping D) d. Irregular pulse or palpitations
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B
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The patient has an order for phenytoin (Dilantin) 100 mg q8hr IV. Available is a phenytoin injection containing 50 mg/ml. How many milliliters of solution should the nurse draw up for the dose? A) a. 0.5 B) b. 2 C) c. 5 D) d. 20
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B
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Which of the following characteristics of a patient's recent seizure is congruent with a partial seizure? A) a. The patient lost consciousness during the seizure. B) b. The seizure involved lip smacking and repetitive movements. C) c. The patient fell to the ground and became stiff for 20 seconds. D) d. The etiology of the seizure involved both sides of the patient's brain.
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B
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Which of the following measures should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? A) a. Vigilant infection control and adherence to standard precautions B) b. Careful monitoring of neurologic vital signs and frequent reorientation C) c. Maintenance of a calorie count and hourly assessment of intake and output D) d. Assessment of blood pressure and monitoring for signs of orthostatic hypotension
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A Infection control is a priority in the care of patients with MS, since infection is the most common precipitator of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in hypotension or fluid volume excess or deficit.
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A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which of the following actions should the health care team take in order to promote adequate nutrition for this patient? A) a. Provide multivitamins with each meal. B) b. Provide a diet that is low in complex carbohydrates and high in protein. C) c. Provide small, frequent meals throughout the day that are easy to chew and swallow. D) d. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.
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C
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Which of the following nursing diagnoses is likely to be a priority in the care of a patient with myasthenia gravis (MG)? A) a. Acute confusion B) b. Bowel incontinence C) c. Activity intolerance D) d. Disturbed sleep pattern
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C The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.
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The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which of the following assessments should the nurse prioritize? A) a. Pain assessment B) b. Glasgow Coma Scale C) c. Respiratory assessment D) d. Musculoskeletal assessment
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C
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Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A) a. Urinary catheterization B) b. Administration of benzodiazepines C) c. Suctioning of the patient's upper airway D) d. Placement of the patient in the Trendelenburg position
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A Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary.
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A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A) a. "I'll try my best to stay out of the sun this summer." B) b. "I know that I probably have a high chance of getting arthritis." C) c. "I'm hoping that surgery will be an option for me in the future." D) d. "I understand that I'm going to be vulnerable to getting infections."
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C SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.
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A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient asks, "What is the most important thing for me to remember?" Which is an appropriate response by the nurse? 1. "Know your family history." 2. "Keep a list of your medications." 3. "Be alert for sudden weakness or numbness." 4. "Call 911 if you notice a gradual onset of paralysis or confusion."
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Correct Answer: 3 Rationale: Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.
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A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching? Select all that apply. 1. how to use a sign board 2. transfer techniques 3. information about impulse control 4. time adjustment to complete activities 5. safety precautions for transferring
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Correct Answer: 1,2,5 Rationale: The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The patient also might display overcautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement.
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A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? 1. "I will stop taking this medicine if I notice any bruising." 2. "I will not eat spinach while I'm taking this medicine." 3. "It will be OK for me to eat anything, as long as it is low fat." 4. "I'll check my blood pressure frequently while taking this medication."
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Correct Answer: 2 Rationale: Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless by prescriber order. Low-fat foods do not interfere with warfarin therapy, which is not prescribed to affect the blood pressure.
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A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which of the following? 1. impending brain death 2. decreasing intracranial pressure 3. stabilization of the patient's condition 4. increased intracranial pressure
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Correct Answer: 4 Rationale: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician. This is an emergency situation that requires intervention as the patient's condition is becoming more unstable. Brain death is diagnosed by lack of brain waves and inability to maintain vital function.
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A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a stroke (CVA). What is the nurse's priority intervention? 1. Move the patient to the critical care unit. 2. Assess blood pressure. 3. Assess the airway and breathing. 4. Observe urinary output.
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Correct Answer: 3 Rationale: In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of highest priority and will continue to be. Blood pressure and output monitoring as well as ensuring appropriate level of care are important interventions, but assessment of the patient's ability to maintain an airway is the most vital.
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A patient whose status is post-stroke (CVA) has severe right-sided weakness. Physical therapy recommends a quad cane. Which of the following is proper use of the cane by the patient? 1. The patient holds the cane in the left hand. The patient moves the cane forward first, then the right leg, and then the left leg. 2. The cane is held in either hand and moved forward at the same time as the left leg. Then the patient drags the right leg forward. 3. The patient holds the cane in the right hand for support. The patient moves the cane forward first, then the left leg, and then the right leg. 4. The patient holds the cane in the left hand. The patient moves the left leg forward first, then moves the cane and the right leg forward together.
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Correct Answer: 1 Rationale: Proper use of the cane is essential to fall prevention. The patient should hold the cane in the left hand. The patient should move the cane forward first, then the right leg, and then the left leg.
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The family of a patient who has had a brain attack (CVA) asks if the patient will ever talk again. The nurse should do which of the following? 1. Explain that the patient's speech will return to normal with time. 2. Explain that it is difficult to know how far the patient will progress. 3. Tell the family that nurses cannot discuss such issues. Tell them to ask the physician. 4. Tell the family what they see today is all they can expect
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Correct Answer: 2 Rationale: Therapeutic communication is needed. It is important to allow hope but be honest by not promising progress, since no one knows how much the patient will improve. Progress may depend on the extent and the areas affected. The nurse does not know that speech will return in time. It is not therapeutic to tell the family to ask the physician, and it does not display a professional, caring attitude.
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The nurse recognizes that the most common type of brain attack (CVA) is related to which of the following? 1. ischemia 2. hemorrhage 3. headache 4. vomiting
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Correct Answer: 1 Rationale: Eighty percent of all strokes are caused by ischemia. Hemorrhagic strokes are less common than ischemic strokes. Headache and vomiting may be symptoms associated with CVA, but not common causes.
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The nurse must be alert to complications in the patient who has suffered a ruptured intracranial aneurysm. The nurse should assess the patient for signs of which of the following? Select all that apply. 1. headache 2. hydrocephalus 3. rebleeding 4. vasospasm 5. stiff neck
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Correct Answer: 1,2,3,4 Rationale: Headache is a sign of a probable rebleed. Hydrocephalus, rebleeding, and vasospasm are the three major complications that a nurse must anticipate following a ruptured intracranial aneurysm. Stiff neck is a manifestation of intracranial aneurysm, not a complication.
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Prodromal manifestations prior to an intracranial aneurysm rupture could be recognized by the nurse as which of the following? Select all that apply. 1. visual deficits 2. headache 3. mild nausea 4. dilated pupil 5. stiff neck
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Correct Answer: 1,2,4 Rationale: Often intracranial aneurysms are asymptomatic until rupture but patients can complain of headache and eye pain, and have visual deficits and a dilated pupil. Nausea and vomiting and stiff neck are not usually associated with the prodromal manifestations of an intracranial aneurysm, but may occur with leaking or rupture.
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A patient is recovering following a carotid endarterectomy. The blood pressure has risen this morning to 168/60. The nurse should do which of the following? 1. Recheck the blood pressure and make sure the correct size cuff was used. Then compare the trend of blood pressure readings and call the physician now. 2. Recheck the blood pressure every hour and report this change to the physician when he or she makes rounds the next time. 3. Record the blood pressure and find out who took this reading. Have that staff member demonstrate his or her blood pressure procedure and offer tips to obtain more accurate readings. 4. Check the standing orders and see if there is a medication ordered p.r.n. for lowering blood pressure. If so, administer it and document the action.
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Correct Answer: 1 Rationale: Take a blood pressure reading manually to check technique, compare the results to the last several blood pressures recorded, and call the physician to report this blood pressure. Physicians typically have a range for maintaining the blood pressure following carotid endarterectomy, with standing orders for higher or lower blood pressures. If the blood pressure becomes higher, it is a danger and should be reported to the physician and documented in the patient record along with orders received. Although the skill of the staff is important, it is a priority to notify the physician of the blood pressure reading so that treatment can begin. Antihypertensives may be ordered and administered p.r.n., but physician notification after verification of the reading is the priority, so that further evaluation can occur.
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The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order? 1. Maintain patent airway 2.record the seizure activity observed 3.ease the client to the floor 4. Obtain vital signs
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Which of the following is contraindicated for a client with seizure precautions? 1. Encouraging him to perform his own personal hygiene. 2. Allowing him to wear his own clothing. 3. Assessing oral temperature with a glass thermometer. 4. Encouraging him to be out of bed.
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3. Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed.
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Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? 1. Jerking in one extremity that spreads gradually to adjacent areas. 2. Vacant staring and abruptly ceasing all activity. 3. Facial grimaces, patting motions, and lip smacking. 4. Loss of consciousness, body stiffening, and violent muscle contractions.
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4. A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.
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Which of the following should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)? 1. Take all the medication until it is gone. 2. Notify the physician if vision changes occur. 3. Store gabapentin in the refrigerator. 4. Take gabapentin with an antacid to protect against ulcers.
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2. Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination should be reported to the physician. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.
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The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has? 1. Drowsiness. 2. Inability to move. 3. Paresthesia. 4. Hypotension.
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1. The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is not typically a problem after a seizure.
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When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: 1. Physical dependency on the drug develops over time. 2. Status epilepticus may develop. 3. A hypoglycemic reaction develops. 4. Heart block is likely to develop.
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2. Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart block.
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Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction? 1. "I will take the medicine before going to bed." 2. "I will drink 6 to 8 glasses of water a day." 3. "I will eat plenty of fresh fruits." 4. "I will take the medicine with a meal or snack."
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2. Toxic effects of topiramate (Topamax) include nephrolithiasis, and clients are encouraged to drink 6 to 8 glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals.
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Which clinical manifestation is a typical reaction to long-term phenytoin sodium (Dilantin) therapy? 1. Weight gain. 2. Insomnia. 3. Excessive growth of gum tissue. 4. Deteriorating eyesight.
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3. A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues must be removed surgically. Phenytoin does not cause weight gain, insomnia, or deteriorating eyesight.
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Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.
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1. A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.
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A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.
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3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.
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During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.
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3. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
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The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? 1. Placing a pillow in the axilla so the arm is away from the body. 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. 3. Immobilizing the extremity in a sling. 4. Positioning a hand cone in the hand so the fingers are barely flexed. 5. Keeping the arm at the side using a pillow.
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1, 2, 4. Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures
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For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.
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2. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.
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Which food-related behaviors are expected in a client who has had a stroke that has left him with homonymous hemianopia? 1. Increased preference for foods high in salt. 2. Eating food on only half of the plate. 3. Forgetting the names of foods. 4. Inability to swallow liquids.
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2. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods would be aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.
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A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? 1. Wear a patch over one eye. 2. Place personal items on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4. Turn the head from side to side when walking.
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4. To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard.
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A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? 1. Sit quietly with the client until the episode is over. 2. Ignore the behavior. 3. Attempt to divert the client's attention. 4. Tell the client that this behavior is unacceptable.
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3. A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.
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What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage.
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3. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
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The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? 1. TIA 2. Embolic stroke 3. Thrombotic stroke Incorrect 4. Subarachnoid hemorrhage
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4. Subarachnoid hemorrhage. Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.
