Question 1

A nursing student studying the neurologic system learns which information? (Select all that apply.)

Accepted Answer

An aneurysm is a ballooning of the weakened part of an arterial wall.Intracerebral hemorrhage is bleeding directly into the brain.Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion.An arteriovenous malformation (AVM)is unusual.Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

Question 2

The nurse working in the emergency department assesses a client who has symptoms of stroke.For what modifiable risk factors should the nurse assess? (Select all that apply.)

Accepted Answer

Alcohol intake,a high-fat diet,obesity,and smoking are all modifiable risk factors for stroke.Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

Question 3

A client has a subarachnoid bolt.What action by the nurse is most important?

Accepted Answer

This device needs frequent balancing and recalibration in order to read correctly.Documenting readings is important,but it is more important to ensure the device's accuracy.The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it,but ensuring the device's accuracy is most important.The phlebostatic axis is not related to neurologic monitoring.

Question 4

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit.Which client should the nurse assess first?

Accepted Answer

The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy.The nurse assesses this client first as he or she may have an intracerebral bleed.The client with meningitis has expected manifestations.The client waiting for discharge teaching is a lower priority.The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA,or the nurse could delegate checking on this client to another nurse.

Question 5

A nurse has applied to work at a hospital that has National Stroke Center designation.The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care.What do these Core Measures include? (Select all that apply.)

Accepted Answer

Core Measures established by The Joint Commission include discharging stroke clients on statins,providing and recording stroke education,and taking measures to prevent venous thromboembolism.The client must be assessed for therapies but may go elsewhere for them.Nutrition goals are not part of the Core Measures.

Question 6

The nurse assesses a client's Glasgow Coma Scale (GCS)score and determines it to be 12 (a 4 in each category).What care should the nurse anticipate for this client?

Accepted Answer

This client will most likely be confused and need frequent re-orientation.The client may not be able to ambulate at all but should do so independently,not because of mental status.Swallowing is not assessed with the GCS.The client will not need near-total care.

Question 7

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI).The nurse notes the presence of an aneurysm clip in the client's record.What action by the nurse is best?

Accepted Answer

Some older clips are metal,which would preclude the use of MRI.The nurse should determine how old the clip is and relay that information to the MRI staff.They can determine if the client is a suitable candidate for this examination.The client does not need to sign informed consent.The provider will most likely not know if the client can have an MRI with this clip.The nurse does not independently change the type of diagnostic testing the client receives.

Question 8

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

Accepted Answer

Heavy drug use,particularly cocaine,is a risk factor for stroke.Heavy alcohol use is also a risk factor,but one beer a day is not considered heavy drinking.Antihistamines may contain phenylpropanolamine,which also increases the risk for stroke,but this client uses them seasonally and there is no information that they are abused or used heavily.The 65-year-old has only age as a risk factor.

Question 9

A client has an intraventricular catheter.What action by the nurse takes priority?

Accepted Answer

All of the actions are appropriate for this client.However,performing hand hygiene takes priority because it prevents infection,which is a possibly devastating complication.

Question 10

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

Accepted Answer

Brain abscesses can lead to seizures as a complication.The nurse should explain this to the spouse.Phenytoin is not used to prevent febrile seizures.Seizures are possible but do not always occur in clients with brain abscesses.This drug is not used for sedation.

Question 11

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

Accepted Answer

Older clients often tolerate stress poorly,which includes being admitted to a hospital that is unfamiliar and noisy.Because of decreased protective mechanisms,they are more susceptible to both local and systemic infections.Other medical conditions can complicate their treatment and recovery.Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes.The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.

Question 12

After a stroke,a client has ataxia.What intervention is most appropriate to include on the client's plan of care?

Accepted Answer

Ataxia is a gait disturbance.For the client's safety,he or she should have assistance and use a gait belt when ambulating.Ataxia is not related to swallowing,aspiration,or voiding.

Question 13

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting.The client's mental status is deteriorating.What action by the nurse is most appropriate?

Accepted Answer

The nurse should attempt to find the family to give consent.If no family is present or can be found,under the principle of emergency consent,a life-saving procedure can be performed without formal consent.The nurse should not just sign the consent form.

Question 14

A nursing student studying traumatic brain injuries (TBIs)should recognize which facts about these disorders? (Select all that apply.)

Accepted Answer

"Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS)score of 9 to 12,and these clients may need to be hospitalized.Both open and closed head injuries can cause a severe TBI,which is characterized by a GCS score of 3 to 8.

Question 15

A client has a small-bore feeding tube (Dobhoff tube)inserted for continuous enteral feedings while recovering from a traumatic brain injury.What actions should the nurse include in the client's care? (Select all that apply.)

Accepted Answer

All of these options are important for client safety when continuous enteral feedings are in use.Blue dye is not used because it can cause lung injury if aspirated.

Question 16

A nurse is working with many stroke clients.Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)

Accepted Answer

Clients most at risk for post-stroke depression are those with a previous history of depression,severe stroke (NIH Stroke Scale score of 38 is severe),and post-stroke physical or cognitive impairment.The client with mild forgetfulness and a slight limp would be a low priority for this referral.

Question 17

A client has a traumatic brain injury and a positive halo sign.The client is in the intensive care unit,sedated and on a ventilator,and is in critical but stable condition.What collaborative problem takes priority at this time?

Accepted Answer

The positive halo sign indicates a leak of cerebrospinal fluid.This places the client at high risk of acquiring an infection.Communication and nutrition are not priorities compared with preventing a brain infection.The client has a definite risk for a skin breakdown,but it is not the immediate danger a brain infection would be.

Question 18

A client has meningitis following brain surgery.What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Accepted Answer

The client with meningitis often has high fever,pain,and some degree of confusion.Cool washcloths to the forehead are comforting and help with pain.Allowing the client to assume a position of comfort also helps manage pain.Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner.The nurse provides antipyretics for fever.

Question 19

A nurse is seeing many clients in the neurosurgical clinic.With which clients should the nurse plan to do more teaching? (Select all that apply.)

Accepted Answer

After a coil procedure,up to 20% of clients experience re-bleeding in the first year.The client with this coil should not be taking drugs that interfere with clotting.An aneurysm clip can move up to 5 years after placement,so this client and family need to be watchful for changing neurologic status.The other statements show good understanding.

Question 20

A nurse is caring for a client after a stroke.What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Accepted Answer

The UAP can take and document vital signs,including oxygen saturation,and keep the client's head in a neutral,midline position with correct direction from the nurse.The nurse assesses the Glasgow Coma Scale score.The nursing staff should not cluster care because this can cause an increase in the intracranial pressure.The head of the bed should be minimally elevated,up to 30 degrees.

Quiz 45: Care of Critically Ill Patients with Neurologic Problems

A nursing student studying the neurologic system learns which information? (Select all that apply.)

The nurse working in the emergency department assesses a client who has symptoms of stroke.For what modifiable risk factors should the nurse assess? (Select all that apply.)

A client has a subarachnoid bolt.What action by the nurse is most important?

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit.Which client should the nurse assess first?

A nurse has applied to work at a hospital that has National Stroke Center designation.The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care.What do these Core Measures include? (Select all that apply.)

The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category) .What care should the nurse anticipate for this client?

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI) .The nurse notes the presence of an aneurysm clip in the client's record.What action by the nurse is best?

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

A client has an intraventricular catheter.What action by the nurse takes priority?

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

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

After a stroke,a client has ataxia.What intervention is most appropriate to include on the client's plan of care?

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting.The client's mental status is deteriorating.What action by the nurse is most appropriate?

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.)

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury.What actions should the nurse include in the client's care? (Select all that apply.)

A nurse is working with many stroke clients.Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)

A client has a traumatic brain injury and a positive halo sign.The client is in the intensive care unit,sedated and on a ventilator,and is in critical but stable condition.What collaborative problem takes priority at this time?

A client has meningitis following brain surgery.What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP) ? (Select all that apply.)

A nurse is seeing many clients in the neurosurgical clinic.With which clients should the nurse plan to do more teaching? (Select all that apply.)

A nurse is caring for a client after a stroke.What actions may the nurse delegate to the unlicensed assistive personnel (UAP) ? (Select all that apply.)