Question 1

Which patient has the best prognosis based on the cause of coma?
A) A 36-year-old man with closed head injury
B) A 50-year-old woman with hepatic encephalopathy
C) A 46-year-old woman with subarachnoid hemorrhage
D) A 72-year-old man with hypertensive intracerebral hemorrhage

Accepted Answer

Prognosis depends on the cause of coma and the length of time unconsciousness persists.Only 15% of patients in nontraumatic coma make a satisfactory recovery.Metabolic coma usually has a better prognosis compared with coma caused by a structural lesion,and traumatic coma usually has a better outcome compared with nontraumatic coma.

Question 2

Nursing management of a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which intervention?
A) Administering osmotic diuretics and vasodilator agents
B) Providing the patient with a quiet environment
C) Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg
D) Keeping the patient's central venous pressure at 5 to 8 mm Hg

Accepted Answer

Hemodynamic augmentation therapy involves increasing the patient's blood pressure and cardiac output with vasoactive medications.Systolic blood pressure is maintained between 150 and 160 mm Hg.The increase in pressure forces blood through the vasospastic area at higher pressures.

Question 3

What is one cause of metabolic coma?
A) Trauma
B) Ischemic stroke
C) Drug overdose
D) Intracerebral hemorrhage

Accepted Answer

Causes of metabolic coma include drug overdose,infectious diseases,endocrine disorders,and poisonings.Structural causes of coma include ischemic stroke,intracerebral hemorrhage,trauma,and brain tumors.

Question 4

When an object is placed in the hand of a patient with neurologic impairment during assessment,the patient is unable to recognize the placement.What is this complication called?
A) Homonymous hemianopsia
B) Aphasia
C) Agnosia
D) Apraxia

Accepted Answer

Agnosia is a disturbance in the perception of familiar sensory (eg,verbal,tactile,visual)information.Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body.Tactile agnosia is a perceptual disorder in which a patient is unable to recognize an object that has been placed in his or her hand by touch alone.Lesions in the parietal lobe and in other cortical structures can result in apraxia,an inability to perform a learned movement voluntarily.Optic radiations extend back to the occipital lobes.Visual defects restricted to a single field,right or left,are called homonymous hemianopsia.Aphasia is a loss of language abilities caused by brain injury,usually to the dominant hemisphere.

Question 5

Ideally fibrinolytic therapy should be administered within how many hours of the onset of stroke symptoms?
A) 1
B) 3
C) 6
D) 10

Accepted Answer

National guidelines for the management of stroke are based on the results of the National Institute of Neurologic Disorders and Stroke rtPA Stroke Study.This study demonstrated that administration of recombinant tissue plasminogen activator within 3 hours of onset of the stroke was an effective and safe therapy for ischemic stroke.This time frame has now been expanded from 3 to 4.5 hours with additional excursion criteria.

Question 6

Which statement is true regarding the occurrence of subarachnoid hemorrhages (SAHs)?
A) Occurrence is greater in men than women younger than the age of 40 years old.
B) Occurrence is greater in men than women older than the age of 40 years old.
C) 90% of SAHs are caused by traumatic injury.
D) Patients with SAHs have a better survival rate than patients with arteriovenous malformations.

Accepted Answer

Among people younger than 40 years,more men than women are likely to have subarachnoid hemorrhages (SAHs); among those older than 40 years,more women have SAHs.Hemorrhage from arteriovenous malformation rupture has a better chance of survival and is associated with an overall mortality rate of 10% to 15%.Ninety percent of aneurysms are congenital,the cause of which is unknown.The other 10% can be the result of traumatic injury (that stretches and tears the muscular middle layer of the arterial vessel)or infectious material.

Question 7

A right-handed patient has been admitted with an intracerebral hemorrhage.A computed tomography (CT)scan of the patient's head reveals a large left parietal area bleed.Based on the type of stroke,which signs and symptoms might the patient exhibit?
A) Right-sided hemiplegia and receptive aphasia
B) Left-sided hemiplegia and tactile agnosia
C) Decorticate posturing and unequal pupils
D) Unilateral neglect and dressing apraxia

Accepted Answer

Damage to the dominant hemisphere produces problems with speech and language and abstract and analytic skills.

Question 8

Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study?
A) Magnetic resonance imaging
B) Noncontrast computed tomography
C) Contrast computed tomography
D) Lumbar puncture

Accepted Answer

Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients.Differentiation from intracranial hemorrhage is vital.Noncontrast computed tomography (CT)scanning is the method of choice for this purpose,and it is considered the most important initial diagnostic study.In addition to excluding intracranial hemorrhage,CT can assist in identifying early neurologic complications and the cause of the insult.Magnetic resonance imaging (MRI)can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis.Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.

Question 9

Which of the following statements regarding Guillain-Barré syndrome (GBS)supports the admission to a critical care unit?
A) The demyelination process of the peripheral nerves is irreversible.
B) The demyelination process is limited to the peripheral nervous system only.
C) The paralysis associated with the syndrome occurs in a descending pattern.
D) The most common cause of death is respiratory arrest.

Accepted Answer

Most patients with Guillain-Barré syndrome (GBS)do not require admission to the critical care unit.However,the prototype of GBS,known as acute inflammatory demyelinating polyradiculoneuropathy (AIDP),involves a rapidly progressive,ascending peripheral nerve dysfunction,which leads to paralysis that may produce respiratory failure.Because of the need for ventilatory support,AIDP is one of the few peripheral neurologic diseases that necessitates care in a critical care environment.

Question 10

Which nursing diagnosis has the highest priority in the nursing management plan for a patient with Guillain-Barré syndrome?
A) Imbalanced nutrition: less than body requirements related to lack of exogenous nutrients or increased metabolic demand
B) Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses
C) Risk for aspiration
D) Ineffective breathing pattern related to musculoskeletal fatigue or neuromuscular impairment

Accepted Answer

The most common cause of death of patients with Guillain-Barré syndrome (GBS)is respiratory arrest; thus,the highest nursing priority for a patient with GBS is directed toward providing ventilatory support and maintaining surveillance for complications.Facilitating nutritional support,providing comfort and emotional support,and educating the patient and family are important but rank lower than issues with the respiratory system.

Question 11

The incidence of rebleeding after a ruptured cerebral aneurysm is highest during which of the following time periods?
A) First 24 hours
B) 4 to 12 days
C) 3 to 4 weeks
D) 3 to 6 months

Accepted Answer

Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or,less commonly,an arteriovenous malformation.The incidence of rebleeding during the first 24 hours after the first bleed is 4%,with a 1% to 2% chance per day for the following month.Mortality with aneurysmal rebleeding is approximately 70%.

Question 12

Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival?
A) Decorticate posturing
B) Absent pupillary light reflexes
C) Decerebrate posturing
D) Central hyperventilation

Accepted Answer

Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest.In a meta-analysis,the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours and lack of motor movement at 72 hours.However,regardless of the cause or duration of coma,the outcome for an individual cannot be predicted with 100% accuracy.

Question 13

A patient has had an ischemic stroke and now having difficulty with speech.The nurse knows the patient is experiencing what problem?
A) Expressive aphasia
B) Global aphasia
C) Receptive aphasia
D) Apraxia

Accepted Answer

Expressive aphasia,also known as motor,Broca,or nonfluent aphasia,is primarily a deficit in language output or speech production.Global aphasia results when a massive lesion affects the motor and sensory speech areas.The patient cannot transform sounds into words and cannot comprehend spoken words.Receptive aphasia,also referred to as sensory,Wernicke,or fluent aphasia,occurs when the connection between the primary auditory cortex in the temporal lobe and the angular gyrus in the parietal lobe is destroyed.Lesions in the parietal lobe and in other cortical structures can result in apraxia,an inability to perform a learned movement voluntarily.

Question 14

What is a pathologic consequence of an unruptured cerebral aneurysm?
A) It shunts blood away from the surrounding tissues.
B) It leaks blood into the subarachnoid space.
C) It causes damage the middle layer of the arterial wall.
D) It places pressure on the surrounding tissues.

Accepted Answer

An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues.The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures,sending arterial blood at a high pressure into the subarachnoid space.

Question 15

A patient presents with aphasia,decreased level of consciousness,and right-sided weakness.The patient has a history of heart disease,hyperlipidemia,and transient ischemic attacks.Based on the history,the nurse suspects that the patient has sustained which type of stroke?
A) Hemorrhagic stroke
B) Intracerebral hemorrhages
C) Subarachnoid hemorrhages
D) Ischemic stroke

Accepted Answer

Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes.The interruption can be the result of a thrombotic or embolic event.Thrombosis can form in large vessels (large-vessel thrombotic strokes)or small vessels (small-vessel thrombotic strokes).Embolic sources include the heart (cardioembolic strokes)and atherosclerotic plaques in larger vessels (atheroembolic strokes).In 30% of the cases,the underlying cause of the stroke is unknown (cryptogenic strokes).Strokes are classified as ischemic and hemorrhagic.Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages and intracerebral hemorrhages.

Question 16

Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents?
A) Epinephrine, hydrocortisone, and Benadryl
B) Dopamine, 10% dextrose in distilled water, and calcium chloride
C) Mannitol, dexamethasone, and sodium bicarbonate
D) Thiamine, glucose, and opioid antagonist

Accepted Answer

The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition.Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration.Protection of the airway and ventilatory assistance are often needed.Administration of thiamine (at least 100 milligrams [mg]),glucose,and an opioid antagonist is suggested when the cause of coma is not immediately known.

Question 17

How often should lubricating eye drops be administered to a patient in coma to prevent corneal epithelial breakdown?
A) 2 hours
B) 4 hours
C) 8 hours
D) 12 hours

Accepted Answer

Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient.In addition,taping a polyethylene film over the eyes,extending from beyond the orbit to over the eyebrow,creates a moisture chamber and has been effective in keeping the eyes moist.

Question 18

A ventriculoperitoneal shunt may be placed in a post-stroke patient to treat which complication?
A) Hyponatremia
B) Intracerebral hemorrhage
C) Spontaneous intracerebral hemorrhage
D) Hydrocephalus

Accepted Answer

Treatment for hydrocephalus consists of placing a drain to remove cerebrospinal fluid.This can be accomplished temporarily by inserting a ventriculostomy or permanently by placing a ventriculoperitoneal shunt.Treatment for hyponatremia is sodium replenishment with isotonic fluids.

Question 19

A male patient post right-sided stroke is experiencing hemiagnosia.This is evidenced by which finding?
A) The patient only reads the right side of the newspaper.
B) The patient refuses to acknowledge the left side of his body.
C) The patient is hyperresponsive when approached on the right side.
D) The patient attempts to comb his hair with a toothbrush.

Accepted Answer

Agnosia is a disturbance in the perception of familiar sensory (eg,verbal,tactile,visual)information.Unilateral neglect is a form of agnosia characterized by an unawareness or denial of the affected half of the body.This denial may range from inattention to refusing to acknowledge a paralysis by neglecting the involved side of the body or by denying ownership of the side,attributing the paralyzed arm or leg to someone else.The neglect also may extend to extrapersonal space.This defect most often results from right hemispheric brain damage that causes left hemiplegia.

Question 20

A right-handed patient has been admitted with an intracerebral hemorrhage.A computed tomography (CT)of the patient's head reveals a large left parietal area bleed.Patient assessment includes temperature (T),98.7° F; pulse (P),98 beats/min and thready; respirations (R),8 breaths/min; and blood pressure (BP),168/100 mm Hg.Initial management of the patient includes which intervention?
A) Placing the patient in the Trendelenburg position
B) Administering an antihypertensive agent
C) Initiating induced hypertensive therapy
D) Intubating and ventilating the patient

Accepted Answer

Intracerebral hemorrhage is a medical emergency.Initial management requires attention to airway,breathing,and circulation.Intubation is usually necessary.Blood pressure management must be based on individual factors.Reduction in blood pressure is usually necessary to decrease ongoing bleeding,but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure,especially in a patient with elevated intracranial pressure.National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg.Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg.

Quiz 23: Neurologic Disorders and Therapeutic Management

Which patient has the best prognosis based on the cause of coma?

Nursing management of a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which intervention?

What is one cause of metabolic coma?

When an object is placed in the hand of a patient with neurologic impairment during assessment,the patient is unable to recognize the placement.What is this complication called?

Ideally fibrinolytic therapy should be administered within how many hours of the onset of stroke symptoms?

Which statement is true regarding the occurrence of subarachnoid hemorrhages (SAHs) ?

A right-handed patient has been admitted with an intracerebral hemorrhage.A computed tomography (CT) scan of the patient's head reveals a large left parietal area bleed.Based on the type of stroke,which signs and symptoms might the patient exhibit?

Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study?

Which of the following statements regarding Guillain-Barré syndrome (GBS) supports the admission to a critical care unit?

Which nursing diagnosis has the highest priority in the nursing management plan for a patient with Guillain-Barré syndrome?

The incidence of rebleeding after a ruptured cerebral aneurysm is highest during which of the following time periods?

Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival?

A patient has had an ischemic stroke and now having difficulty with speech.The nurse knows the patient is experiencing what problem?

What is a pathologic consequence of an unruptured cerebral aneurysm?

A patient presents with aphasia,decreased level of consciousness,and right-sided weakness.The patient has a history of heart disease,hyperlipidemia,and transient ischemic attacks.Based on the history,the nurse suspects that the patient has sustained which type of stroke?

Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents?

How often should lubricating eye drops be administered to a patient in coma to prevent corneal epithelial breakdown?

A ventriculoperitoneal shunt may be placed in a post-stroke patient to treat which complication?

A male patient post right-sided stroke is experiencing hemiagnosia.This is evidenced by which finding?