MDC IV exam1

*A client with a left middle cerebral artery ischemic stroke 2 days ago is experiencing a visual field deficit. Which nursing intervention is best to ensure client safety?

Place the call light on the client's left side

*A client with a traumatic brain injury is at risk for venous thromboembolism (VTE). Which actions should the nurse take? SATA

-Administer anticoagulant therapy as prescribed.

-Reposition client in bed every 2 hours.

-Apply sequential compression devices (SCDs)

A client has a comminuted fracture of T6-T7, resulting in paraplegia. The nurse educates the client on preventing autonomic dysreflexia. Which of the following is the priority intervention to avoid this medical emergency?

Preventing bladder distension

A patient with a coup-contrecoup injury reports vision problems. Which brain area is most likely involved?

Occipital lobe

A patient with a traumatic brain injury (TBI) is exhibiting signs of increased intracranial pressure (ICP). How should you apply evidence-based care to prioritize this patient's needs?

Position the head of bed at thirty degrees to promote venous drainage

Which orders should the nurse anticipate for immediate treatment of the stroke client? SATA

-Peripheral IV access

I-ntravenous labetalol

-Intravenous alteplase

-Continuous cardiac monitoring

-Swallow evaluation

-Aspiration precautions

After a middle cerebral artery stroke, a patient shows difficulty understanding spoken words. Which brain area is most likely compromised?

Wernicke's area

A client with MS has new onset of sharp shooting pain in the face triggered by brushing the teeth. What do you do?

Change to soft bristle toothbrush and encourage gentle oral hygiene

A client with a traumatic brain injury is at risk for developing increased intracranial pressure (ICP). Which actions should the nurse take to maintain ICP within normal range? SATA

-Monitor arterial blood gas values to assess the adequacy of ventilation.

-Monitor neurological status using the Glasgow Coma Scale.

-Elevate the head of the bed at least 30 degrees.

A client with a recent history of head trauma is exhibiting episodes of disorientation and restlessness. Which condition is the client most likely experiencing?

delirium

A client has experienced a seizure in which they became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?

Generalized seizure

client w/ history of hypertension, hyperlipidemia, atrial fibrillation, hypothyroidism, & 30-year smoking history presents to the emergency department w/ sudden onset left-sided weakness, left facial droop, & slurred speech that began an hour ago. client is tachycardic w/ a regular rhythm. Lung sounds - clear bilaterally w/ no dyspnea. Abdomen soft, round, and nontender w/ active bowel sounds. client is evaluated for cerebrovascular accident versus transient ischemic attack. A 12-lead EKG is performed at 1000, IV labetalol is given @ 1015, & a head CT at 1030 confirms ischemic stroke w/ no evidence of bleeding. Client is transferred to the progressive care unit at 1130, placed in high Fowler's position, alert and interacting w/ family, w/ the call light & bed in a low position. At 1600, client has decreased level of consciousness, restlessness, irritability, and inappropriate responses to questions & headache

The patient is experiencing increased intracranial pressure

In a patient with a CNS disorder and irregular respiratory patterns, what is the nurse's immediate action?

Ensure a clear airway to support proper breathing

A nurse is caring for a client who underwent a transsphenoidal approach for pituitary tumor removal. Postoperatively, the client exhibits signs of diabetes insipidus. Which medication should the nurse plan on administering?

Vasopressin

A client presents to the emergency department with a sudden onset of symptoms indicative of a stroke. Which of the following assessments would be most important for the nurse to prioritize in the immediate evaluation? SATA

-Neurological assessment including NIH Stroke Scale

-Temperature

-Blood pressure

-Heart rate

A nurse is planning care for a client with a right hemispheric stroke. Which goal is most appropriate for this client?

The client will exhibit improved spatial-perceptual orientation within one week

A client with a supratentorial lesion is exhibiting early signs of increased intracranial pressure. Which assessment finding would require immediate intervention?

Pupillary changes and impaired extraocular movements

Client with a history of hypertension, hyperlipidemia, atrial fibrillation, hypothyroid, and smoking 1 pack per day for 30 years experiences sudden onset of left-sided weakness one hour prior to arriving to the emergency department. Left facial droop is noted with slurred speech. The client is noted to have tachycardia with an irregular rhythm. Lung sounds are clear to auscultation bilaterally and there is no dyspnea noted. abdomen is round, soft, & with active bowel sounds. The client is to be evaluated in the emergency department for cerebrovascular accident versus transient ischemic attack. 1000-12-lead EKG prescribed and performed showing atrial fibrillation 1015-IV labetalol is administered. 1030 Head CT confirms ischemic stroke and rules out any evidence of bleeding.Vital Signs: 2/6 Time Blood Pressure Heart Rate Respiratory Rate Temperature SpO2 0900 198/94 118 20 99.2 F 98% RA 1045 175/90 110 18 99.2 F 98% RA

Intravenous alteplase

Bell's Palsy interventions

Tape your eye shut at night and use eye drops during the day

A client with Multiple Sclerosis is experiencing a relapse, they have new symptoms, how do we treat exacerbation?

Steroid therapy (IV methylprednisolone)

A herniated lumbar disc patient is scheduled for a microdiscectomy, what is the postop care?

Log roll the patient

A patient with Parkinson's presents with a new onset of weakness and fatigue, which is suggestive of post-polio syndrome. What should the nurse evaluate?

Help with their ability to perform ADLs

A patient with a Supratentorial lesion has early signs and symptoms of increased ICP, what assessment requires immediate intervention?

Extraocular movement, pupils dilated on the unaffected side

A nurse is caring for a client with herpes simplex encephalitis. Which actions should the nurse take in planning care for this client? SATA

-Monitor the client for the development of seizures. -Administer intravenous acyclovir slowly over one hour.

-Maintain bedrest and avoid activity

Education for an epileptic patient going home?

do not discontinue medication

A nurse is educating a client with epilepsy on lifestyle modifications to prevent seizure activity. Which recommendations should the nurse include? SATA

-Avoid alcoholic beverages and other seizure triggers.

-Do not abruptly stop taking your anticonvulsant medications.

A client with a history of epilepsy is being discharged home. What should the nurse include in the discharge teaching?

Maintain a consistent medication schedule to keep drug levels constant

A client is admitted with a sudden onset of right-sided weakness and slurred speech resulting from a left hemispheric ischemic stroke. Which nursing intervention is most appropriate to prevent complications?

Assist with passive range-of-motion exercises to the affected side.

Caring for a patient with hypertension and diabetes, admitted with the sudden onset of right-sided weakness, slurred speech, due to a left-sided ischemic stroke. What is the most appropriate action by the nurse? SATA

-CT scan

-blood sugar

-NPO

-prevent contractures

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol?

Alcohol causes vasodilation of blood vessels. (increased ICP)

A client presents to the emergency department after a fall, and a CT scan reveals a subdural hematoma. Which assessment finding would require immediate intervention?

Sudden deterioration in level of consciousness and focal neurologic deficits. (Assess LOC, focal and neurological deficits)

A recent stroke patient is undergoing a motor functional assessment, when they attempt to hold both arms with palms up, one arm drifts.

Opposite lesion

Major concern of myasthenia gravis?

Respiratory

A client presents with a history of seizures and is scheduled for an EEG. The nurse notes that the client consumed coffee and cola prior to the test. What is the nurse's best next action?

Inform the healthcare provider and discuss the possibility of postponing the EEG.

The nurse cares for a client who presents with neck stiffness, light sensitivity, and muscle aches. After the initial assessment, what are the nurse's priority interventions? SATA

-Assess the client's ocular movement.

-Close the door and turn down the television volume.

-Place the client on droplet precautions.

-Elevate the head of the bed to 35 degrees

A nurse is assessing a client with a suspected arteriovenous malformation (AVM) to monitor potential vasospasm. The nurse understands which diagnostic tool is used to detect the vasospasm?

Transcranial doppler

Right hemisphere stroke goals?

Improved spatial orientation within one week

What would you do first for a patient with glioblastoma?

Medicate for the headache and notify the PCP

Guillain-Barré's biggest risk

respiratory failure risk

A patient with a spinal cord tumor, patient is experiencing localized pain. What are the nursing interventions?

assess their pain and give analgesics

Taking care of a patient with a brain abscess, the ICP is increased. What are the nursing interventions?

Elevate the head of the bed 30 degrees and keep the body midline

Trigeminal neuralgia patient is scheduled for a microvascular decompression surgery, what do we monitor for post op?

facial motor and sensory deficits

A client with a recent stroke is undergoing a motor function assessment. The nurse observes that when the client attempts to hold both arms out with palms up, one arm slowly pronates and drifts downward. What does this finding suggest?

A possible lesion on the opposite side of the pronating arm.

A client who has suffered a hemorrhagic stroke is experiencing increased intracranial pressure. Which of the following interventions should the nurse take first?

Administer mannitol as prescribed

While performing a neurological assessment on a stroke patient, a nurse observes a decline in the patient's condition. What immediate action should the nurse take?

Notify the physician immediately using SBAR

A nurse is preparing a patient for surgery. The patient mentions they ate a light breakfast that morning. Which action should the nurse take to apply evidence-based safety strategies during the perioperative phase?

Notify the provider in anticipation of delaying the procedure.

A client with a brain tumor is scheduled for supratentorial surgery. Which preoperative medication would be most appropriate to reduce the risk of postoperative complications of seizures?

Phenytoin

A mother brings her 6-year-old daughter to the pediatric clinic due to episodes of frequent staring spells. The mother reports the child suddenly stops activity, stares blankly for several seconds, and then resumes normal behavior. The child is unaware that the episodes occur. The teacher reports these episodes happen multiple times a day during class.

Order an electroencephalogram (EEG) -indicated

Initiate antiseizure medication -indicated

Increase dosage of antiseizure medication - not indicated

Hold current antiseizure medication - Not indicated

Provide caregiver education and counseling- indicated

3 multiple choice options

which cranial nerve tests smell

olfactory- CN I

3 multiple choice options

which cranial nerve tests Vision

optic- CN II

3 multiple choice options

which cranial nerve tests Eye movement, pupil response

Oculomotor/Trochlear/Abducens- CN III, IV, VI

3 multiple choice options

which cranial nerve tests Facial sensation, jaw movement

Trigeminal- CN V

3 multiple choice options

which cranial nerve tests Facial expressions, taste

Facial- CN VII

3 multiple choice options

which cranial nerve tests Hearing, balance

Vestibulocochlear- CN VIII

3 multiple choice options

which cranial nerve tests Gag, swallow, voice quality

Glossopharyngeal/Vagus- CN IX/X

2 multiple choice options

which cranial nerve tests Shoulder shrug

Spinal Accessory- CN XI

which cranial nerve tests Tongue movement

Hypoglossal- CN XII

what would a glasgow coma scale of <8 indicate

coma

what are late signs of cerebral edema and ICP

Cushing's Triad, ↑ SBP with widening pulse pressure, ↓ HR

(BRADYCARDIA), Irregular respirations, Posturing: decorticate (hands inward at chest) or decerebrate (hands inward at sides)

1 multiple choice option

what are early signs of cerebral edema and ICP

Decreased LOC (first and most sensitive), Headache, Pupillary changes (sluggish or unequal), Visual changes, Vomiting (not preceded by nausea), Restlessness, irritability

1 multiple choice option

what is apasia

speech impairment

which area of the brain is likely affected when a stroke patient is experiencing aphsia

left frontal or temporal lobe

3 multiple choice options

which area of the brain is likely affected when a stroke patient is showing signs od neglect/ impulse control

Right parietal lobe

3 multiple choice options

which area of the brain is likely affected when a stroke patient is experiencing ataxia

Cerebellum

3 multiple choice options

which area of the brain is likely affected when a stroke patient is experiencing vision loss

Occipital lobe

3 multiple choice options

Agnosia

inability to recognize objects

Dysphagia

difficulty swallowing

Hemianopsia

half visual field loss

Ataxia

loss of muscle coordination

what is a hemorrhagic stroke

bleeding into brain tissue

common causes of hemorrhagic stroke

HTN, aneurysm rupture, AVM, trauma,

anticoagulant use

Myasthenia gravis: When planning care, the client is at highest risk for which complication?

Aspiration

Levodopa effectiveness: A client with Parkinson's disease is prescribed levodopa therapy. Improvement in which area indicates the therapy is effective?

Muscle rigidity

Stroke alert priority info: Before initiating a stroke alert, what does the healthcare team need to know?

Glasgow coma scale

Post-thrombolytics priority: During the first 24 hours after thrombolytic treatment for ischemic stroke, the nurse's primary goal is to control which vital sign?

Blood pressure

General anesthesia teaching: Which statement indicates correct understanding of general anesthesia?

"I am having general anesthesia, so I will be given a gas to breathe and medication in my IV."

IV immunoglobulin response: Myasthenia gravis—IV immunoglobulin is for which response?

Increases the production of acetylcholine antibodies

Migraine beta-blocker teaching: Teaching for a client prescribed a daily beta-blocker for migraine management—what instruction is appropriate?

Take this drug as ordered even when feeling well to prevent vascular changes associated with migraines

Ergotamine action: Ergotamine tartrate medications are beneficial in migraine headaches due to which action?

Constrict cerebral blood vessels

Status epilepticus: Which medication will the nurse administer for status epilepticus?

Lorazepam/Diazepam

Pulmonary embolus finding: Sudden chest pain with dyspnea, cyanosis, and tachycardia are symptoms of which complication?

Pulmonary embolus

Migraine prevention meds: Which statement shows correct understanding of migraine management?

Verapamil or propranolol are not abortive meds; they help manage and prevent migraines

Head injury CSF leak teaching: Client has head injury with drainage from nose/ears—priority teaching?

Wipe the nose/ears, but do not blow the nose or place anything in the ear

Guillain-Barre history clue: Which statement correlates with Guillain-Barre syndrome?

: "I just got over the flu a couple of weeks ago and now this."

Embolic stroke + echo: Client asks why they need a heart test after embolic stroke—best response?

Most of these types of blood clots come from the heart

tPA contraindication priority: Ischemic stroke client cannot have fibrinolytic therapy until which vital sign is addressed?

Blood pressure 220/120

Glasgow Coma Scale components: GCS identifies 3 areas of assessment as which of the following?

: Eye-opening, best motor response, verbal response

Motorcycle accident with increased ICP—most significant sign?

Decreased level of consciousness

Which finding is congruent with the postictal state?

The client's motor function is returning to baseline

High potassium pre-op: Client due to receive general anesthesia has K+ 5.8 mEq/L. Nurse first response?

Notify the surgeon

Client cannot wrinkle forehead or pucker lips, stroke ruled out—discharge teaching on which disorder?

Bell's palsy

Craniotomy/hematoma: Which intervention decreases threat of increased intracranial pressure after craniotomy?

Elevate head of bed 30 degrees

Basilar skull fracture halo sign: Nurse notes halo sign drainage—what should nurse do next?

Check for presence of glucose in drainage and report to provider

Which type of anesthesia requires both inhalation and IV administration?

General anesthesia

Client says "I didn't understand but I trust him." Best nurse response?

"I need to contact your surgeon so your questions can be answered."

: Loss of ability to recognize familiar objects/people through sensory stimulation is?

Agnosia

Dysphagia swallowing intervention: Stroke client dysphagia (esp liquids). Best intervention?

Instruct the client to tuck the chin when swallowing

healthcare team considering tPA. What must nurse do first?

Identify the time of onset of the stroke

Nurse witnesses a seizure—priority action?

Place the client on their side (left-lateral position)

Post-stroke expressive aphasia—best nursing intervention for communication?

Provide pictures or a communication board to help communicate