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35 Cards in this Set
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A patient admitted in the ER after an MVA reported having a stiff neck and fluid discharge leaking from his nose. In testing the fluid discharge, the nurse would note the discharge to be CSF if the fluid:
a. Is bright red, and tested positive for glucose b. Is clear yellow, and has a foul odor c. Has a yellowish stain surrounding blood, and tested positive for glucose d. Has a yellowish stain surrounding blood, and tested negative for glucose |
C. Has a yellowish stain surrounded by blood, and tested positive for glucose
CSF placed on a white absorbent background can be distinguished from other fluids by the “halo” sign – a yellowish stain surrounded by bloody drainage. If it’s present, it tests positive for glucose using a strip testing method. (ch. 47, p 1055) |
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The nurse is taking the medical history of a patient admitted after having a transient ischemic attack (TIA). Which of the following findings would place the patient at greater risk of having a stroke?
a. Family history of hypertension b. Use of a CPAP during bedtime c. Intake of high protein, high carb diet d. Long term aspirin use |
A. Family history of hypertension
Major risk factors that increase the likelihood of strokes include cigarette smoking, previous TIA, diabetes, obesity, and family history of hypertension or atherosclerotic disease. (ch. 47, p 1032-1033) |
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Which of the following would be present in a patient who had a stroke that affected the right-side of the brain?
a. Aphasia b. Right visual field deficits c. Disorientation to time, place, and person d. Slowness |
C. Disorientation to time, place, and person
The right cerebral hemisphere is more involved w/ visual and spatial awareness and proprioception. A person who has a stroke involving the right cerebral hemisphere may be disoriented to time and place. (ch. 47, p 1034) |
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The nurse is caring for a patient admitted after having a stroke. When caring for the patient, the nurse noted that the patient leans to the left side whenever he’s on the wheelchair. The nurse would document the patient’s behavior as indicator of:
a. Hemanopsia b. Ptosis c. Flaccid paralysis d. Neglect syndrome |
D. Neglect syndrome
In neglect syndrome, the patient is unaware of the existence of his left or paralyzed side. When questioned, the patient often states that everything is fine and believes that he is sitting up straight in the chair. (ch. 47, p 1035) |
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Which of the following drugs would the nurse prepare to administer for a patient who experienced a stroke 24 hours ago?
a. Lasix b. Aspirin c. Lisinopril d. Ancef |
B. Aspirin
An initial dose of 325 mg of aspirin is recommended within 24-48 hours after onset of stroke. Aspirin shouldn’t be given within 24 hours after rtPA administration. (ch. 47, p 1043) |
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Which of the following interventions shouldn’t be included in the care plan for a patient who developed aphasia after a cerebrovascular accident?
a. Use “yes” and “no” questions for patients w/ expressive aphasia b. Use alternative forms of communication if needed, such as a computer or flash cards c. Speak slowly but not loudly d. Avoid asking patients to do multiple tasks |
A. Use “yes” and “no” questions for patients w/ expressive aphasia
“yes” and “no” questions should be avoided for patients w/ expressive aphasia because they often give automatic responses that may be incorrect. (ch. 47, p 1046) |
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A patient is admitted in the ICU after an acute ischemic stroke and is now receiving rtPA thrombolytic therapy. The patient reports having a headache, and feeling nauseous. What should be the nurse’s next action?
a. Insert an NG tube to prevent aspiration b. Reassure patient that symptoms are normal during rtPA therapy c. Give an intial dose of aspirin d. Notify physician |
D. Notify physician
Until stable, invasive tubes such as an NG tube shouldn’t be placed on the patient after rtPA administration to prevent bleeding. Infusion should be DC’ed and physician should be notified if patient reports severe headaches, or has nausea / vomiting. Aspirin shouldn’t be given within 24 hours after rtPA therapy. (ch. 47, p 1037) |
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Which of the following should the nurse note as the first sign of increased ICP for a patient who had a stroke?
a. Bradycardia b. Decline in LOC c. Hypertension d. Dilated and fixed pupils |
B. Decline in LOC
The first sign of increased ICP is a declining level of consciousness (LOC). Cushing’s triad, a classic but late sign of increased ICP is manifested by severe hypertension w/ a widening pulse pressure, and bradycardia. (ch. 47, p 1043, 1054) |
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A patient diagnosed w/ a hemorrhagic stroke has undergone a craniotomy procedure. The nurse caring for the patient should include which of the following interventions in the plan of care for the patient?
a. Perform neck or hip flexion exercises Q4H b. Monitor neurological status every shift c. Administer stool softener BID d. Encourage patient to do coughing exercises as tolerated |
C. Administer stool softener BID
Patient is at risk for increased ICP whenever performing a valsalva maneuver when straining during defecation. Patients should avoid coughing exercises after craniotomy to prevent increased ICP. (ch. 47, p 1038-1042) |
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A nurse is preparing to administer Mannitol IV for a patient to decrease ICP. To reduce the incidence of rebound from the drug, the nurse will also prepare to administer which medication?
a. Furosemide b. Fentanyl c. Versed d. Aspirin |
A. Furosemide
Furosemide (Lasix) is often used as adjunctive therapy to reduce incidence of rebound from mannitol. It also enhances the therapeutic action of mannitol. (ch. 47, p 1057) |
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A patient w/ a C5 spinal injury has a weak respiratory effort, ineffective cough, and uses accessory muscles when breathing. Which of the following nursing diagnoses would be most appropriate for the patient?
a. Risk for aspiration b. Risk for injury c. Ineffective breathing pattern d. Impaired gas exchange |
C. Ineffective breathing pattern
Ineffective breathing pattern is diagnosed when the respiratory rate, rhythm, depth are insufficient for optimal ventilation. Impaired gas exchange occurs when oxygenation or CO2 elimination is altered at alveolar-capillary membrane. (ch. 47, p 997) |
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A patient is placed on seizure precautions after admission. Which of the following interventions is contraindicated for the patient?
a. Place a saline lock on patient b. Suction machine at bedside c. Administer valium PRN d. Place padded tongue blades at bedside |
D. Place padded tongue blades at bedside
Padded tongue blades don’t belong at the bedside and should never be inserted into patient’s mouth because the jaw may clench down as soon as seizure begins. (ch. 44, p 959) |
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A home health nurse is visiting a patient diagnosed w/ multiple sclerosis who is taking oxybutynin (Ditropan). The nurse evaluates effectiveness of the medication by asking the patient which of the following questions?
a. Are you having any muscle spasms? b. Do you get up at night to urinate? c. Are you feeling fatigue? d. Are you having normal bowel movements? |
B. Do you get up at night to urinate?
Oxybutynin (Ditropan) is an antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in patients w/ uninhibited or reflex neurogenic bladder. (ch. 45, p 1005-1006) |
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A patient who had a stroke has a right-sided hemanopsia. Which of the following interventions help the patient adapt to the visual deficit?
a. Ensure that patient wears her eyeglasses at all times b. Place objects within the right visual field c. Place objects within the left visual field d. Teach patient to scan the environment |
D. Teach patient to scan the environment
Scanning the environment allows the patient to take in the entirety of the visual field. Eyeglasses are useful but they will not correct the visual deficit. (ch. 47, p 1035) |
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A nurse is ordered to perform an assessment on a newly admitted patient diagnosed with a C4 spinal injury. In performing the assessment, which of the following should the nurse perform first?
a. Assess LOC b. Check blood pressure c. Listen to breath sounds d. Assess CMS |
C. Listen to breath sounds
The patient with a cervical SCI is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, which controls the diaphragm. (ch. 45, p 993) |
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A patient w/ a C5 SCI complains of pain and sudden headache. Upon further assessment, the nurse noted the patient’s BP is 180/110 and the patient is diaphoretic. Which of the following should be the nurse’s first action?
a. Place patient in sitting position b. Notify physician c. Give Apresoline IVP d. Loosen tight clothing |
A. Place patient in sitting position
The patient is experiencing signs and symptoms of autonomic dysreflexia. The first priority is to place the patient in a sitting position to prevent hypertensive stroke. (ch. 45, p 998) |
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During assessment of a patient admitted after a head injury, the patient’s companion reported that the patient momentarily lost consciousness at the time of injury and then regained it. The patient now has lost consciousness again. The nurse should take immediate action because the patient is experiencing:
a. Subdural hematoma b. Cerebrovascular attack (stroke) c. Epidural hematoma d. Neurogenic shock |
C. Epidural hematoma
Patients w/ epidural hematomas have “lucid intervals” that lasts for minutes during which time the patient is awake and talking. This follows a momentary unconsciousness that occurs within minutes of injury. After initial interval, symptoms progress very quickly w/ catastrophic ICP elevation. (ch. 47, p 1051) |
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A nurse is caring for the patient w/ a C5 SCI who experienced spinal shock. To evaluate patient’s recovery from spinal shock, the nurse would assess for:
a. Reflexes b. Blood pressure c. Abdominal distention d. CSF leak |
A. Reflexes
Spinal shock occurs immediately as a response to injury. The patient has flaccid paralysis and loss of reflex activity below the level of lesion. After shock has resolved, the reflexes may return if the lesion is incomplete or involved upper motor neurons. (ch. 45, p 993-994) |
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A patient w/ an upper cervical SCI received discharge teaching about measures to prevent autonomic dysreflexia. Which of the following statements made by the patient indicate a need for further teaching?
a. I have to avoid wearing tight clothing b. I should watch for symptoms such as chest pain or fever c. I should check how often I move my bowels d. I should check my bed linens and blankets for wrinkles |
B. I should watch for symptoms such as chest pain or fever
Symptoms of autonomic dysreflexia include sudden onset of severe headache, severe hypertension, facial flushing, and nausea. Chest pain and fever aren’t associated with the condition. (ch. 45, p 998) |
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A patient begins to experience a seizure activity while in bed. Which of the following nursing action is most appropriate for the patient to prevent aspiration?
a. Restrain patient using padded bands b. Raise the head of bed c. Position patient to side, with head flexed forward d. Lower side rails and bed to lowest position |
C. Position patient to side, with head flexed forward
Positioning the patient to the side w/ head flexed forward allows the tongue to fall forward and facilitates drainage of secretions. Patient shouldn’t be restrained because this may cause injury and worsen the situation. (ch. 44, p 959) |
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A nurse is observing a patient admitted after a closed brain injury for increased ICP. Which of the following are signs and symptoms of increased ICP? [select all that apply]
a. Hypotension b. Headache c. Tachycardia d. Fever e. Abnormal posturing f. Slurred speech |
B. Headache
E. Abnormal posturing F. Slurred speech Manifestations of increased ICP include headache, hypertension, bradycardia, abnormal posturing (decerebrate/decorticate), and slurred speech. (ch. 47, p 1037) |
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A nurse received report on a patient who had a right-cerebral stroke. Upon assessment of the patient, the nurse would note which of the following as manifestations of right-cerebral stroke? [select all that apply]
a. Neglect of the left visual field b. Difficulty with writing c. Inability to comprehend language d. Impulsiveness e. Reading problems f. Paralysis of the right side of the body |
A. Neglect of the left visual field
D. Impulsiveness The right cerebral hemisphere is more involved w/ visual and spatial awareness. Patients who have a right cerebral stroke may have personality changes that include impulsivity and poor judgment. The left cerebral hemisphere is the center of language, math skills, and analytic thinking. Left cerebral stroke results in inability to comprehend language, difficulty writing, and reading problems. (ch. 47, p 1034) |
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In observing an ambulating patient diagnosed w/ Parkinson’s disease, the nurse would note which of the following gait features?
a. Unsteady and staggering steps b. Broad, and waddling gait c. Slow, shuffling steps d. Fast, propulsive toe-walking |
C. Slow, shuffling steps
Gait features of patients w/ Parkinson’s disease are characterized by short, accelerating, shuffling steps. The patient leans forward w/ head, hips, and knees flexed, and has difficulty stopping quickly. (ch. 44, p 966) |
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A patient who had a C4 SCI 12 hours ago was admitted to the ICU. Which of the following initial assessment findings would have the highest priority that requires for an immediate intervention?
a. Temp = 101F b. Pulse = 50 c. Cool, clammy skin d. Slight abdominal distention |
B. Pulse = 50
Neurogenic shock may occur within 24 hours after an SCI above T6. It is a type of hypovolemic shock causing severe bradycardia, warm, dry skin, and severe hypotension. It is an immediate emergency and is treated by restoring fluids to circulating blood volume. (ch. 45, p 995) |
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A nurse is ordered to administer IV Solu-Medrol for the patient who has a cervical SCI. Which of the following should the nurse monitor for the patient receiving the medication?
a. Liver function b. Risk for seizures c. Glucose level d. Respiration rate |
C. Glucose level
The patient receiving IV Solu-medrol should be closely monitored for adverse effects, including infection, elevated serum glucose levels, and stress ulcers. (ch. 45, p 996) |
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The nurse in the ICU is caring for a patient after an MVA. Which assessment findings would indicate that the patient would be at risk for developing a hemorrhagic stroke?
a. Fine crackles on both bases of the lungs b. BP = 200/160 c. Blood glucose level = 250 mg/dL d. Pulse = 100 |
B. BP = 200/160
Hemorrhage into the brain tissue generally results from a ruptured aneurysm, rupture of an arteriovenous malformation, or more commonly, severe hypertension. (ch. 47, p 1031) |
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A patient is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which of the following teaching instructions should be implemented for the patient?
a. Instruct patient to stay awake for 12 hours prior to the EEG b. Tell patient to avoid eating or drinking for at least 8 hours prior to the procedure c. Instruct patient to remove all metal objects (jewelry, earrings, hairpins, etc.) prior to the procedure d. Assess patient for any allergic reaction to iodine or shellfish |
A. Instruct patient to stay awake for 12 hours prior to EEG
The goal for the patient is to have a seizure during the EEG procedure. Sleep deprivation, hyperventilation, or strobe light stimulation may induce a seizure. (ch. 43, p 947) |
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A patient is admitted in the ICU for a closed head trauma. The patient experienced a seizure episode that lasted for 5 minutes during admission and has been having 5-minute-long seizures for every 10 minutes. The nurse would prepare to administer which medication for the patient?
a. Mannitol IV b. SubQ heparin c. IV recombinant tissue plasminogen activator (rtPA) d. Diazepam IV push |
D. Diazepam IV push
Status epilepticus is a medical emergency and is a prolonged seizure lasting longer than 5 minutes or repeated seizures over the course of 30 minutes. The drug of choice for treating status epilepticus are IV push lorazepam or diazepam. (ch. 44, p 959-960) |
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Which clinical manifestations would be noted in a patient diagnosed w/ Parkinson’s disease?
a. Jugular vein distention and dry skin b. Muscle weakness in the upper extremities and ptosis c. Orthostatic hypotension and masklike facies d. Exaggerated arm swinging and ataxia |
C. Orthostatic hypotension and masklike facies
Clinical features of Parkinson’s disease include orthostatic hypotension, and masklike facies; changes in facial expression w/ wide-open eyes caused by rigidity of the facial muscles. (ch. 44, p 966) |
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A patient w/ a closed head injury is admitted to the ICU. Which of the following is an appropriate short-term goal for the patient?
a. Patient will maintain optimal level of functioning b. Patient’s ICP will not be more than 15 mmHg c. Patient will not develop contractures d. Patient will not require long-term rehabilitation for the injury |
B. Patient’s ICP will not be more than 15 mmHg
Specific nursing interventions for the patient w/ a head injury are directed toward preventing or detecting increased ICP, promoting fluid and electrolyte balance, and monitoring effects of drug therapy. (ch. 47, p 1055) |
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A patient is admitted with a head injury after being involved in a MVA. Upon assessment, the nurse notes clear fluid draining from the left ear. The nurse would suspect:
a. Epidural hematoma b. Linear skull fracture c. Basilar skull fracture d. Subdural hematoma |
C. Basilar skull fracture
A basilar skull fracture occurs at the base of the skull, usually extending into the anterior, middle, or posterior fossa and results in CSF leakage from the nose or the ears. (ch. 47, p 1050) |
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An ICU nurse is monitoring a patient who had an epidural hematoma. The patient’s vital signs were: pulse 44, BP 200/160, respirations 16 and irregular. What should be the nurse’s first action?
a. Increase IV fluids b. Administer ordered rtPA thrombolytic therapy c. Administer anti-hypertensive medication d. Decrease IV fluids |
D. Decrease IV fluids
The patient is experiencing signs of increased ICP. Fluid overload can occur and cerebral edema can worsen from rapid administration of IV fluids or plasma expanders. (ch. 47, p 1057) |
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A nurse is performing discharge teaching regarding drug therapy for a patient w/ generalized seizures. Which of the following statements should be included in the teaching?
a. Take drug even if there is no seizure activity b. Drug must be taken on an empty stomach c. Therapeutic drug levels are reached after 2-3 weeks d. Tolerance from the drug may result after long-term use |
A. Take drug even if there is no seizure activity
Drug must not be stopped even if the seizures have stopped. Discontinuing the drugs can lead to recurrence of seizures or the life-threatening complication of status epilepticus. (ch. 44, p 958) |
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Which of the following signs and symptoms are not present in a patient diagnosed w/ Parkinson’s disease?
a. Fine tremors on both hands when performing an activity b. “pill-rolling” movement of fingers c. Uncontrolled drooling d. Difficulty chewing and swallowing |
A. Fine tremors on both hands when performing an activity
Early signs and symptoms of Parkinson’s disease are tremors at rest (“pill-rolling”), rigidity to passive movement of extremities (“cogwheeling”), and bradykinesia (slow movement). (ch. 44, p 966) |
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A patient expresses concern that she may have multiple sclerosis. Which of the following signs and symptoms reported by the patient would help determine presence of multiple sclerosis?
a. Fatigue and stiffness of the legs b. Hand tremors at rest c. Increased sensitivity to pain d. Anxiety and hallucinations |
A. Fatigue and stiffness of the legs
The patient w/ multiple sclerosis often reports increased fatigue and stiffness of the extremities, particularly the legs. Other key features include tremors during activity, blurred vision, and decreased sensitivity to pain. Depression is the most frequent psychiatric disorder diagnosed in patients w/ multiple sclerosis. (ch. 45, p 1003-1004) |
