Chapter 41 Critical Care of Patients with Neurologic Emergencies

Which motor symptoms of a transient ischemic attack (TIA) will the nurse recognize when a client experiences this neurologic dysfunction? Select all that apply. A. Blurred vision B. Facial droop C. Weakness in hand grasp D. Aphasia E. Difficulty walking F. Lack of balance B, C, E, F 2. Which client assessment finding will help the nurse to differentiate a transient ischemic attach (TIA) from a brain attack (stroke)? A. Unilateral weakened hand grasp B. Slurred speech C. Symptoms resolve within 30 to 60 minutes D. One-sided numbness of face and arm C 00:24 01:14 3. Which collaborative actions will the nurse expect when a client with TIA is admitted to the hospital? Select all that apply. A. Performing a carotid angioplasty with stenting to increase perfusion to the brain B. Prescribing and teaching about antiplatelet drugs such as aspirin or clopidogrel C. Teaching the client about the benefits of taking vitamin supplements D. Prescribing and teaching about antihypertensive drugs to lower blood pressure E. Promoting lifestyle changes such as smoking cessation, healthy eating, and exercise F. Teaching the client to use a cane or walker for stability and balance A, B, D, E 4. What actions will the nurse take to determine if an altered level of consciousness (LOC) in a client is a neurologic emergency, or if it represents one of two other conditions that may also lead to altered LOC? A. Observe for jaundice and abdominal distention. B. Check blood glucose and oxygen saturation. C. Observe for jugular vein distention and pitting edema. D. Check skin turgor and perform a bladder scan. B 5. Which medication will the nurse administer to a client to prevent harm from recurrence of a stroke? A. Gabapentin B. Acetaminophen C. Alteplase D. Enteric-coated aspirin D 6. Which symptoms will the nurse teach the client and family to report to the health care provider immediately after a carotid stent placement procedure, but before discharge? Select all that apply. A. Severe headache B. Muscle weakness C. Shortness of breath D. Severe neck pain E. Difficulty swallowing F. Blurred vision A, B, D, E 7. What is the nurse’s best first action when a client with an ischemic stroke now has a systolic blood pressure of 192 mm Hg? A. Notify the Rapid Response Team or primary health care provider immediately. B. Raise the head of the bed to a position of comfort for the client. C. Instruct the client to relax and take several deep breaths. D. Position the client supine and recheck the blood pressure every 5 to 10 minutes. A 8. Which instruction would the nurse give an assistive personnel (AP) providing morning care for a client with increased intracranial pressure (ICP)? A. Give the bath, change the linens, do passive range of motion and then allow the client to rest. B. Give the bath, allow rest, change the linen, allow rest, perform passive range of motion, allow rest. C. Give the bath, then defer the linen change and range of motion exercises until the client is out of danger. D. Look at the client’s orders for specifics about activities related to increased ICP that might cause an additional rise in ICP. B 9. Which clients will the nurse monitor for increased risk of stroke? Select all that apply. A. 43-year-old healthy woman who used oral contraceptives B. 66-year-old man with type 2 diabetes mellitus C. 47-year-old woman who exercises 5 to 6 days a week D. 35-year-old man with a history of several transient ischemic attacks E. 55-year-old woman with facial muscle weakness due to Bell’s palsy F. 73-year-old man with chronic alcoholism A, B, D, F 10. Within which time frame does the nurse expect administration of intravenous fibrinolytic therapy with alteplase to occur related to a client’s stroke symptoms onset? A. 24 to 30 hours B. 6 to 8 hours C. 3 to 4.5 hours D. 30 to 60 minutes C 11. What is the nurse’s best action when a client seems to have difficulty with swallowing? A. Limit the diet to clear liquids given only through a straw. B. Withhold food and fluids until swallowing is assessed and tested. C. Observe the client while eating and note which foods are problematic. D. Monitor the client’s weight and food intake, then compare current trends to baseline. B 12. Which guiding principles will the nurse use to best determine actions that will help with communications for a stroke client with aphasia? Select all that apply. A. Present just one idea or thought in a sentence. B. Use simple one-step commands. C. Speak slowly and loudly avoiding the use of cues. D. Avoid yes and no questions for a client with sensory aphasia. E. Use alternative forms of communication such as a communication board. F. Do not rush the client when speaking. A, B, E, F