Chapter 47: Care of Critically Ill Patients with Neurologic Problems Nursing School Test Banks

Chapter 47: Care of Critically Ill Patients with Neurologic Problems

Test Bank

MULTIPLE CHOICE

1. 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?

a.

Seizures

b.

Psychotropic drug use

c.

Atrial fibrillation

d.

Cerebral aneurysm

ANS: C

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.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 1012

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

2. 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?

a.

Two episodes of speech difficulties in the last month

b.

Sudden loss of motor coordination

c.

A grand mal seizure 2 months ago

d.

Chest pain and nuchal rigidity

ANS: A

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.

DIF: Cognitive Level: Comprehension/Understanding REF: Table 47-1, p. 1006

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

3. 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 clients family to help determine whether the coma is related to a brain attack?

a.

How many hours does your mother usually sleep at night?

b.

Did your mother complain recently of weakness in her lower extremities?

c.

Is any history of seizures known among your mothers immediate family?

d.

Does your mother drink any alcohol or take any medications?

ANS: D

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 clients risk of coma.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. 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?

a.

Impaired proprioception

b.

Aphasia

c.

Agraphia

d.

Impaired olfaction

ANS: A

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 clients ability to write.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

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?

a.

Poor left-sided motor control

b.

Paralysis or contractures on the right side

c.

Limited visual perception of the left fields

d.

Unawareness of the existence of her left side

ANS: D

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 clients sight. This is not related to poor motor control or paralysis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1011

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

6. 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?

a.

Shoulder subluxation

b.

Flaccid hemiparesis

c.

Pathologic fracture

d.

Neglect syndrome

ANS: A

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

7. 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?

a.

Turn the clients plate around halfway through the meal.

b.

Place the client in high Fowlers position.

c.

Order a clear liquid diet for the client.

d.

Verbalize the placement of food on the clients plate.

ANS: B

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 Fowlers 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 clients diet to clear liquids.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

8. 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?

a.

Check the clients blood pressure and apical heart rate.

b.

Elevate the back rest to 30 degrees and notify the health care provider.

c.

Place the client in a supine position with a flat back rest, and observe.

d.

Assess the clients white blood cell count and differential.

ANS: B

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

9. 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?

a.

Administer prescribed analgesics to promote pain relief.

b.

Cluster nursing procedures together to avoid fatiguing the client.

c.

Monitor neurologic and vital signs closely to identify early changes in status.

d.

Position with the head of the bed flat to enhance cerebral perfusion.

ANS: C

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 clients neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

10. 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?

a.

Tissue plasminogen activator

b.

Heparin sodium

c.

Gabapentin (Neurontin)

d.

Warfarin (Coumadin)

ANS: A

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

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

a.

Repeated syncope

b.

New-onset confusion

c.

Spontaneous ecchymosis

d.

Abdominal distention

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Evaluation)

12. 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?

a.

Position the client with the unaffected side down.

b.

Apply sequential compression stockings.

c.

Instruct the client to turn the head from side to side.

d.

Teach the client to touch and use both sides of the body.

ANS: B

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

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

a.

Inability to comprehend spoken words

b.

Communication with rote speech only

c.

Slurred speech

d.

Inability to make sounds

ANS: A

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Sensory/Perceptual Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

14. 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?

a.

Rehabilitation will reverse any physical deficits caused by the stroke.

b.

If you do not have rehabilitation, you may never walk again.

c.

Rehabilitation will help you function at the highest level possible.

d.

Your doctor knows best and has ordered this treatment for you.

ANS: C

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

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

a.

Decrease your oral intake of fluids to 1 liter per day.

b.

Use a Foley catheter at night to prevent accidents.

c.

Plan to use the commode every 2 hours during the day.

d.

Hold your bladder as long as possible to restore bladder tone.

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

16. 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?

a.

Aspiration

b.

Hemorrhage

c.

Pulmonary embolus

d.

Myocardial infarction

ANS: B

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

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

a.

Pupil response

b.

Motor function

c.

Respiratory status

d.

Short-term memory

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

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

a.

You should expect a full recovery in all ways by the time of discharge.

b.

Usually, someone with this type of injury returns to baseline within 6 months.

c.

Your brother may experience many changes in personality and cognitive abilities.

d.

Learning complex new skills may be more difficult, but you can expect other functions to return to normal.

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Implementation)

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

a.

These drugs will prevent her from experiencing pain when positioning or suctioning is required.

b.

This medication will help her remain cooperative and calm during the painful treatments.

c.

This medication will decrease the activity of her brain so that additional damage does not occur.

d.

This medication will prevent her from having a seizure and will reduce the need for monitoring intracranial pressure.

ANS: C

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

20. 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?

a.

Draw up the medication using a filtered needle.

b.

Have injectable naloxone (Narcan) prepared and ready at the bedside.

c.

Prepare to hyperventilate the client before drug administration.

d.

Discontinue a barbiturate-induced coma before drug administration.

ANS: A

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

21. A client with a head injury is being given midazolam (Versed) while on mechanical ventilation. Which action does the nurse implement for this client?

a.

Monitor for seizures.

b.

Assess for urinary output.

c.

Provide a clear liquid diet.

d.

Administer an analgesic.

ANS: D

Midazolam (Versed) is a benzodiazepine agent and has no analgesic effect. It should be given with pain medication. This medication does not increase the risk of seizures and does not decrease urinary output. Clients should not be fed when being mechanically ventilated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

22. The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client?

a.

Ask the family to bring in pictures familiar to the client.

b.

Turn on the television to a 24-hour news station.

c.

Maintain a calm and quite environment by minimizing visitors.

d.

Provide auditory and visual stimulation simultaneously.

ANS: A

For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

23. The nurse is planning the discharge of a client who has sustained a moderate head injury and is experiencing personality and behavior changes. The clients wife states, I am concerned about how different he is. What can I do to help with the transition back to our home? How does the nurse respond?

a.

Be firm and let him know when his behavior is unacceptable.

b.

Minimizing the number of visitors will help stabilize his personality.

c.

Developing a routine will help provide him with a structured environment.

d.

He will return to his normal emotional functioning in 6 to 12 months.

ANS: C

Developing a home routine that provides structure and repetition is recommended because clients with personality and behavior problems respond best to this type of environment. The clients personality and emotional functioning will never return to normal. The client may be aggressive, and family members must be aware of potential client reactions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Family Dynamics)

MSC: Integrated Process: Teaching/Learning

24. The nurse assesses periorbital edema and ecchymosis around both eyes of a client who is 6 hours postoperative for craniotomy. Which intervention does the nurse implement for this client?

a.

Position the client with the head of the bed flat.

b.

Apply an ice pack to the affected area.

c.

Assess arterial blood pressure.

d.

Notify the health care provider.

ANS: B

Periorbital edema and ecchymosis are expected after a craniotomy. The nurse should attempt to increase the clients comfort by reducing the swelling with application of ice. The provider does not need to be notified. Lowering the head of the bed and assessing blood pressure will not decrease inflammation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

25. The nurse is assessing a client who was recently diagnosed with a meningioma. Which statement indicates that the client correctly understands the diagnosis?

a.

This is the worst type of brain tumor, and surgery is not an option.

b.

My tumor can be removed, but I can still have damage because of pressure in my brain.

c.

Even after the surgery, I will need chemotherapy to decrease the spread of the tumor.

d.

Radiation is never used on brain tumors because of possible nerve damage.

ANS: B

Meningiomas arise from the coverings of the brain (the meninges) and are the most common type of benign tumor. This tumor is encapsulated, globular, and well demarcated, and causes compression and displacement of nearby brain tissue. Although complete removal of the tumor is possible, it tends to recur and causes irreversible damage to the brain. The tumor is not treated by chemotherapy or radiation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Evaluation)

MULTIPLE RESPONSE

1. A client is admitted for evaluation of a cerebral tumor. Which clinical manifestations does the nurse assess this client for?

a.

Hemiplegia

b.

Aphasia

c.

Hearing loss

d.

Behavior changes

e.

Nystagmus

ANS: A, B, D

If the tumor affects the cerebral hemispheres, hemiplegia, aphasia, and behavioral changes are common. Hearing loss and nystagmus are found with brainstem lesions.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 47-10, p. 1032

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

COMPLETION

1. The nurse is preparing to administer a prescribed dose of intravenous dexamethasone (Decadron) to a client after craniotomy. The pharmacy supplies dexamethasone 40 mcg in 20 mL normal saline to be administered over 15 minutes. The nurse sets the IV pump at a rate of _____ mL/hr.

ANS:

80

20 mL/15 min = x mL/60 min

15x = 1200

x = 80 mL/hr

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesDosage Calculation)

MSC: Integrated Process: Nursing Process (Implementation)

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