Question 1

A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center.The client asks,"Why do I need rehabilitation?" How does the nurse respond?

Accepted Answer

The goal of rehabilitation is to maximize the client's abilities in all aspects of life.The other responses do not answer the client's question appropriately.

Question 2

A client has experienced a stroke resulting in damage to Wernicke's area.Which clinical manifestation does the nurse monitor for?

Accepted Answer

The client with damage to Wernicke's area cannot understand spoken or written words.If the client speaks,the language is meaningless,with the client using made-up words.Damage to Wernicke's area does not cause slurred speech,nor will the client communicate with habitual speech only.

Question 3

The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skull fracture.Which complication of this injury does the nurse monitor for?

Accepted Answer

This type of fracture may cause hemorrhage from damage to the internal carotid artery.The other problems are not complications of this injury.

Question 4

The nurse is caring for a client who has experienced a stroke.Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment?

Accepted Answer

Cranial nerve IX,the glossopharyngeal nerve,controls the gag reflex.Clients with impairment of this nerve are at great risk for aspiration.The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present.The client would not have vision problems.Turning the plate around would not prevent a complication,nor would limiting the client's diet to clear liquids.

Question 5

A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face.How does the nurse interpret these actions?

Accepted Answer

Clients who have experienced a right hemisphere stroke often have neglect syndrome,in which they are unaware of the existence of the paralyzed side,or the left side.This injury would not have an effect on the client's sight.This is not related to poor motor control or paralysis.

Question 6

A client who has a head injury is transported to the emergency department.Which assessment does the emergency department nurse perform immediately?

Accepted Answer

Respiratory derangements (e.g.,hypoxemia,hypercarbia,alterations in pH)can contribute to secondary brain injury in this scenario.Therefore,the important priority is assessment of respiratory status so that secondary brain injury conditions are avoided.The other assessments should be performed after effective respiratory functions have been established.

Question 7

The nurse is caring for a client who had a stroke.Which nursing intervention does the nurse implement during the first 72 hours to prevent complications?

Accepted Answer

Early detection of neurologic,blood pressure,and heart rhythm changes offers an opportunity to intervene in a timely fashion.Evidence is not yet sufficient to recommend a specific back rest elevation after stroke.Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications.Preventing fatigue is not a priority in the first 72 hours.

Question 8

A client who has a severe head injury is placed in a drug-induced coma.The client's husband states,"I do not understand.Why are you putting her into a coma?" How does the nurse respond?

Accepted Answer

When intracranial pressure cannot be controlled by other means,clients may be placed in a barbiturate coma to decrease cerebral metabolic demands,decrease formation of vasogenic edema,and produce a more uniform blood supply to the brain.The other responses do not correctly explain the reason for a medication-induced coma.Pain medication should be administered when the client is comatose.

Question 9

The nurse is assessing a client who had a stroke in the right cerebral hemisphere.Which neurologic deficit does the nurse assess for in this client?

Accepted Answer

A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness.The client may present with impaired proprioception and may be disoriented as to time and place.The right cerebral hemisphere does not control speech,smell,or the client's ability to write.

Question 10

The nurse is preparing to administer prescribed mannitol (Osmitrol)to a client with a severe head injury.Which precaution does the nurse take before administering this medication?

Accepted Answer

Mannitol (Osmitrol)must be drawn up using a filtered needle to eliminate microscopic crystals.Narcan does not reverse the effects of mannitol.Hyperventilation does not affect administration of this drug,and clients can be given mannitol while in a barbiturate-induced coma.

Question 11

A client who had a stroke is receiving clopidogrel (Plavix).Which adverse effect does the nurse monitor for in this client?

Accepted Answer

Clopidogrel (Plavix)is an antiplatelet medication that can cause bleeding,bruising,and liver dysfunction.The nurse should be alert for signs of bleeding,such as ecchymosis,bleeding gums,and tarry stools.Plavix does not cause syncope,confusion,or abdominal distention.

Question 12

The nurse notes that the left arm of a client who has experienced a brain attack is in a contracted,fixed position.Which complication of this position does the nurse monitor for in this client?

Accepted Answer

Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder.Contractures are stiff and immobile-not flaccid.Contractures are not caused by fractures or neglect syndrome.

Question 13

A client who had a brain attack was admitted to the intensive care unit yesterday.The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking.What does the nurse do next?

Accepted Answer

The client is experiencing signs of increased intracranial pressure (ICP).Raising the head of the bed would help decrease ICP.The health care provider should then be notified immediately so that other interventions to reduce ICP can be instituted.Assessing vital signs and white blood cell count is not the priority at this time.

Question 14

The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack.Which disorder does the nurse identify as a predisposing factor for an embolic stroke?

Accepted Answer

Clients with a history of hypertension,heart disease,atrial fibrillation,diabetes,obesity,and hypercoagulopathy are at risk for embolic stroke.The other disorders are not risk factors for an embolic stroke.

Question 15

A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit.Which prescribed medication does the nurse prepare to administer?

Accepted Answer

The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA)to dissolve the cerebral artery occlusion and re-establish blood flow.Clients must meet eligibility criteria for administration of this therapy.The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke.

Question 16

The nurse is caring for a client who has a moderate head injury.The client's sister asks,"Will my brother return to his normal functioning level when his brain heals?" How does the nurse respond?

Accepted Answer

Those with moderate to severe head injuries are never the same as before the injury.They can experience changes in cognition such as memory loss,difficulty learning new information,and limited concentration.Personality alterations such as outbursts of temper and depression also may occur.The other responses do not correctly answer the question and can give false hope.

Question 17

The nurse is teaching bladder training to a client who is incontinent after a stroke.Which instruction does the nurse include in this client's teaching?

Accepted Answer

To begin a bladder training program,teach the client to use the commode,bedpan,or urinal every 2 hours.If used frequently enough,this will prevent accidents and establish a routine.Fluid intake should be restricted at night,and a Foley catheter should be used only for urine retention.The client should empty his or her bladder when the urge occurs and should not hold the bladder.

Question 18

The nurse is caring for an 80-year-old client who presented to the emergency department in a coma.Which question does the nurse ask the client's family to help determine whether the coma is related to a brain attack?

Accepted Answer

Conditions such as drug or alcohol intoxication,as well as hypoxemia and metabolic disturbances,can cause profound changes in level of consciousness (LOC)when accompanied by a brain attack.Alcohol abuse and medication toxicity can be especially problematic in older adults.The other manifestations are related to a stroke but would not increase the client's risk of coma.

Question 19

The nurse is caring for a client who is immobile from a recent stroke.Which intervention does the nurse implement to prevent complications in this client?

Accepted Answer

To avoid complications of immobility,such as deep vein thrombosis,the nurse applies sequential compression stockings or pneumatic compression boots.Efforts are made to mobilize the client as much as possible,and the client should be repositioned frequently.The other interventions will not prevent complications of immobility.

Question 20

A client with aphasia presents to the emergency department with a suspected brain attack.Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke?

Accepted Answer

Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs),causing a focal neurologic dysfunction.Two episodes of speech difficulties would correlate with TIAs.The other manifestations are not related to a thrombotic stroke.

Quiz 47: Care of Critically Ill Patients With Neurologic Problems