Chapter 41: Critical Care of Patients With Neurologic Emergencies Ignatavicius: Medical-Surgical Nursing, 10th Edition

1. A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently the client's neurologic examination is normal. About what drug would the nurse plan to teach the patient?

a. Alteplase

b. Clopidogrel

c. Heparin sodium

d. Mannitol

Clopidogrel

2. The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke?

a. Age greater than or equal to 75

b. Blood pressure greater than or equal to 160/95

c. Unilateral weakness during a TIA

d. TIA symptoms lasting less than a minute

Unilateral weakness during a TIA

3. The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke?

a. Client's symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy.

c. Client reported severe headache before other symptoms.

d. Client has a long history of atrial fibrillation.

d. Client has a long history of atrial fibrillation.

4. A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time?

a. Assess the client for hypoglycemia and hypoxia.

b. Place the client on his or her side.

c. Prepare for administration of a fibrinolytic agent.

d. Start a continuous IV heparin sodium infusion.

a. Assess the client for hypoglycemia and hypoxia.

5. The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching?

a. "I will use "yes" and "no" questions when communicating with the client."

b. "I will remind the client frequently to not get out of bed without help."

c. "I will offer a urinal every hour to the client due to incontinence."

d. "I will feed the client slowly using soft or pureed foods."

b. "I will remind the client frequently to not get out of bed without help."

6. A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client?

a. Assess for bladder and bowel retention and/or incontinence.

b. Listen to the client's lungs after eating or drinking for diminished breath sounds.

c. Support the client's left side when sitting in a chair or in bed.

d. Remind the client to move her head from side to side to increase her visual field.

d. Remind the client to move her head from side to side to increase her visual field.

7. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?

a. Loss of bladder control

b. Other medical conditions

c. Progression of symptoms

d. Time of symptom onset

d. Time of symptom onset

8. The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department.

b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion.

c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously.

d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy

d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy

9. A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action?

a. Perform a comprehensive pain assessment.

b. Discontinue the infusion of the drug.

c. Conduct a neurologic assessment.

d. Administer an antihypertensive drug

b. Discontinue the infusion of the drug.

10. A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met?

a. Chooses preferred items from the menu.

b. Eats 75 to 100% of all meals and snacks.

c. Has clear lung sounds on auscultation.

d. Gains 2 lb (1 kg) after 1 week.

c. Has clear lung sounds on auscultation

11. A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate?

a. "He is NPO until the speech-language pathologist performs a swallowing evaluation."

b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger."

c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration."

d. "Be sure to sit him up when you are feeding him to make him feel more natural."

a. "He is NPO until the speech-language pathologist performs a swallowing evaluation."

12. A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care?

a. Ambulate only with a gait belt.

b. Encourage double swallowing.

c. Monitor lung sounds after eating.

d. Perform postvoid residuals.

a. Ambulate only with a gait belt.

13. A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke?

a. A 27-year-old heavy-cocaine user.

b. A 30-year-old who drinks a beer a day.

c. A 40-year-old who uses seasonal antihistamines.

d. A 65-year-old who is active and on no medications.

a. A 27-year-old heavy-cocaine user.

14. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client?

a. Projectile vomiting

b. Dilated and nonreactive pupils

c. Severe hypertension

d. Decreased level of consciousness

d. Decreased level of consciousness

15. A client is admitted with a traumatic brain injury. What is the nurse's priority assessment?

a. Complete neurologic assessment

b. Comprehensive pain assessment

c. Airway and breathing assessment

d. Functional assessment

c. Airway and breathing assessment

16. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate?

a. Explain that personality changes are common following brain injuries.

b. Ask the client why he or she is acting out and behaving differently.

c. Refer the client and spouse to a head injury support group.

d. Tell the spouse that this is expected and he or she will have to learn to cope.

a. Explain that personality changes are common following brain injuries.

17. The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first?

a. Client with amnesia for the incident

b. Client who has a Glasgow Coma Scale score of 12

c. Client with a PaCO2 of 36 mm Hg and on a ventilator

d. Client who has a temperature of 102° F (38.9° C)

d. Client who has a temperature of 102° F (38.9° C)

18. A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate?

a. Request a directive form the client's primary health care provider.

b. Ask the family if they agree to organ donation for the client.

c. Wait until brain death is determined before acting on organ donation.

d. Contact the local organ procurement organization as soon as possible.

d. Contact the local organ procurement organization as soon as possible.

19. After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first?

a. Assess the client's urinary output.

b. Assess the client's serum sodium level.

c. Increase the rate of the IV infusion.

d. Provide oral care every hour.

b. Assess the client's serum sodium level.

20. A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process?

a. Cardiac dysrhythmias

b. Loss of consciousness

c. Nausea and vomiting

d. Fever

a. Cardiac dysrhythmias

21. A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client?

a. Phenytoin

b. Lorazepam

c. Mannitol

d. Morphine

c. Mannitol

22. A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct?

a. "Increased pressure from the tumor can cause seizures."

b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors."

d. "This drug is used to sedate with a brain tumor."

a. "Increased pressure from the tumor can cause seizures."

The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.)

a. Heavy alcohol intake

b. Diabetes mellitus

c. Elevated cholesterol

d. Obesity

e. Smoking

f. Hypertension

a. Heavy alcohol intake

b. Diabetes mellitus

c. Elevated cholesterol

d. Obesity

e. Smoking

f. Hypertension

Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.)

a. Blood pressure control

b. Aspirin use

c. Smoking cessation

d. Low carbohydrate diet

e. Cholesterol management

f. Increased red wine consumption

a. Blood pressure control

b. Aspirin use

c. Smoking cessation

e. Cholesterol management

A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment findings will the nurse expect? (Select all that apply.)

a. Ataxia

b. Dysphagia

c. Aphasia

d. Apraxia

e. Hemiparesis/hemiplegia

f. Ptosis

b. Dysphagia

c. Aphasia

d. Apraxia

e. Hemiparesis/hemiplegia

f. Ptosis

The nurse is preparing for discharge of a client who had a carotid artery angioplasty with stenting to prevent a stroke. For which signs and symptoms with the nurse teach the family to report to the primary health care provider immediately? (Select all that apply.)

a. Muscle weakness

b. Hoarseness

c. Acute confusion

d. Mild neck discomfort

e. Severe headache

f. Dysphagia

a. Muscle weakness

b. Hoarseness

c. Acute confusion

e. Severe headache

f. Dysphagia

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.)

a. Hyperoxygenate the client before and after suctioning.

b. Avoid sudden or extreme hip or neck flexion.

c. Provide oxygen to maintain an SaO2 of 95% or greater.

d. Maintain the client in a supine position at all times.

e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

a. Hyperoxygenate the client before and after suctioning.

b. Avoid sudden or extreme hip or neck flexion.

c. Provide oxygen to maintain an SaO2 of 95% or greater.

e. Avoid clustering care nursing activities and procedures.

A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.)

a. Admission can overwhelm the coping mechanisms for older clients.

b. Alcohol is typically involved in most traumatic brain injuries for this age-group.

c. These clients are more susceptible to systemic and wound infections.

d. Other medical conditions can complicate treatment for these clients.

e. Very few traumatic brain injuries occur in this age-group.

a. Admission can overwhelm the coping mechanisms for older clients.

c. These clients are more susceptible to systemic and wound infections.

d. Other medical conditions can complicate treatment for these clients.

A nurse is caring for a group of stroke patients. Which clients would the nurse consider referring to a mental health provider? (Select all that apply.)

a. Female client who exhibits extreme emotional lability

b. Male client with an initial National Institutes of Health (NIH) Stroke Scale score of 38

c. Female client with mild forgetfulness and a history of depression

d. Male client who has a past hospitalization for a suicide attempt

e. Male client who is unable to walk or eat 3 weeks poststroke

a. Female client who exhibits extreme emotional lability

b. Male client with an initial National Institutes of Health (NIH) Stroke Scale score of 38

c. Female client with mild forgetfulness and a history of depression

d. Male client who has a past hospitalization for a suicide attempt

e. Male client who is unable to walk or eat 3 weeks poststroke

8. A nurse is discharging a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.)

a. Does not want to purchase a thermometer.

b. Is allergic to acetaminophen.

c. Laughing, says "Strenuous? What's that?"

d. Lives alone and is new in town with no friends.

e. Plans to have a beer and go to bed once home.

b. Is allergic to acetaminophen.

d. Lives alone and is new in town with no friends.

e. Plans to have a beer and go to bed once home.

The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.)

a. Sensitivity to light and sound

b. Reports "feeling foggy"

c. Unconscious for an hour after injury

d. Elevated temperature

e. Widened pulse pressure

a. Sensitivity to light and sound

b. Reports "feeling foggy"

The nurse would recognize which signs and symptoms as consistent with brainstem tumors? (Select all that apply.)

a. Hearing loss

b. Facial pain

c. Nystagmus

d. Vomiting

e. Hemiparesis

a. Hearing loss

b. Facial pain

c. Nystagmus