Deck 42: Nursing Care of People With Cerebrovascular and Spinal Cord Disorders

Question 1

The family of a person who has had a brain attack (CVA)asks if the person will ever talk again. What should the nurse do?

A)Explain that the person's speech will eventually return to normal.
B)Tell the family that it is unlikely that there will be any improvement.
C)Tell the family that nurses cannot discuss such issues. Tell them to ask the doctor.
D)Explain that it is difficult to know how far the person will progress.

Answer 1

Explain that it is difficult to know how far the person will progress.

Question 2

A person has severely impaired physical mobility in the days immediately after having had a stroke. What is appropriate nursing care for this person?

A)Assess for changes in deep tendon reflexes.
B)Turn the person every two hours.
C)Turn the person every shift.
D)Perform passive ROM exercises every two hours.

Answer 2

Turn the person every two hours.

Question 3

The most common type of brain attack (CVA)is related to which of the following?

A)Migraines.
B)Ischaemia.
C)Haemorrhage.
D)Seizures.

Answer 3

Ischaemia.

Question 4

While caring for the person with a spinal cord injury (SCI), the nurse elevates the head of the bed, removes TED stockings and continues to assess vital signs every 2-3 minutes, while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is:

A)tachycardia.
B)elevated blood pressure.
C)peripheral vascular shutdown.
D)bradypnoea.

Question 5

Which person would be most at risk for a stroke (CVA)?

A)A person with heart disease.
B)A person with hypertension.
C)A person with elevated blood cholesterol levels.
D)A person who is a substance abuser.

Question 6

A hospitalised person has become unresponsive. The left side of the body is flaccid. The attending doctor believes the person may have had a stroke (CVA). What is the nurse's priority intervention?

A)Monitor any deterioration in urinary output.
B)Perform neurological observations.
C)Assess the airway and breathing.
D)Assess blood pressure.

Question 7

Which of the following persons is at highest risk of a spinal cord injury?

A)23-year-old man who plays basketball.
B)20-year-old female with a history of substance abuse.
C)18-year-old male with a prior motor vehicle accident.
D)50-year-old female with osteoporosis.

Question 8

The person is exhibiting left-sided hemianopia (loss of visual field)following a stroke (CVA). What is the priority of nursing care? To:

A)train the person to scan the right side of the body.
B)explain that the person must pay more attention to objects in front of them.
C)teach the person to scan his or her surroundings.
D)train the person to scan the left side of his or her body.

Question 9

The nurse must be alert to complications in the person who has just had a ruptured intracranial aneurysm. What should the nurse assess the person for? (Select all that apply.)

A)Hydrocephalus.
B)Vasospasm.
C)Rebleeding.
D)Photophobia.

Question 10

A person with a spinal cord injury (SCI)has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation?

A)Apraxia.
B)Neglect syndrome.
C)Paraplegia.
D)Quadriplegia.

Question 11

The nurse is caring for a person with increased intracranial pressure (IICP). The nurse realises that some nursing actions are contraindicated with IICP. Which nursing action should be avoided?

A)Reposition the person every two hours.
B)Position the person with the head of the bed elevated 20 degrees.
C)Provide continuous oxygen as ordered.
D)Suction the airway every two hours.

Question 12

A person is recovering following a carotid endarterectomy. The person's blood pressure has risen this morning to 168/60. What should the nurse do?

A)Recheck the blood pressure every 30 minutes and report this change to the doctor when they make rounds the next time.
B)Record the blood pressure and find out who took this reading. Have that staff member demonstrate their blood pressure procedure and offer tips to obtain more accurate readings.
C)Check the standing orders and see if there is a medication ordered PRN for lowering blood pressure. If so, administer it and document the action.
D)Recheck the blood pressure and ensure the correct size cuff was used. Compare the trend of blood pressure readings and call the doctor now.

Question 13

When caring for a person just admitted post-stroke (CVA), who has altered consciousness, the nurse should place the person in which position?

A)Flat.
B)High Fowler's.
C)Side-lying.
D)Prone.

Question 14

The nurse understands that when the spinal cord is injured, ischaemia results and oedema occurs. How should the nurse explain to the person the reason that the extent of injury cannot be determined for several days to a week?

A)'The oedema extends the level of injury for two cord segments above and below the affected level.'
B)'Tissue repair does not begin for 72 hours.'
C)'Death of spinal nervous tissue does not occur until days after the injury.'
D)'Neurons need time to regenerate, so stating the extent of the injury too early is not predictive of how the person progresses.'

Question 15

A person is admitted with signs of a stroke (CVA). On admission, vital signs were blood a pressure of 128/70, pulse 68, and respirations 20. Two hours later, the person 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. What do these findings suggest?

A)Embolic stroke.
B)Developing hemiplegia.
C)Decreasing intracranial pressure.
D)Increased intracranial pressure.

Question 16

A person with a spinal cord injury is recovering from spinal shock. The nurse realises that the person should not develop a full bladder, because what emergency condition can occur if it is not corrected quickly?

A)Autonomic rebound.
B)Autonomic crisis.
C)Autonomic shutdown.
D)Autonomic dysreflexia.

Question 17

The person is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output and palpation of a distended bladder. What are these signs consistent with?

A)Developing hypovolaemia.
B)High cervical injury.
C)Spinal shock.
D)Paralysis.

Question 18

A lumbar puncture (LP)is done on a person to rule out a spinal cord tumour. The cerebrospinal fluid (CSF)is xanthochromic (yellow colour), has increased protein, no cells, and clots immediately. What syndrome indicative of a spinal cord tumour do these findings describe?

A)Nephrotic syndrome.
B)Dysreflexia syndrome.
C)Cord tumour syndrome.
D)Froin's syndrome.

Question 19

The nurse is caring for a person with a secondary metastatic spinal cord tumour. What would be the benefit of surgery?

A)Exploration to obtain a biopsy.
B)To remove part of the tumor, to reduce spinal cord compression.
C)To eliminate the tumour with excision and drainage.
D)Complete removal of the tumour and affected spinal cord tissue.

Question 20

What are prodromal manifestations prior to an intracranial aneurysm rupture? (Select all that apply.)

A)Visual deficits.
B)Headache.
C)Frequent nausea.
D)Eye pain.