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 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 13. Which actions will the nurse delegate to the assistive personnel (AP) providing care for a client with right cerebral hemisphere damage? Select all that apply. A. Suggest that the family bring in familiar family photos. B. Move the client’s bed so that his or her unaffected side faces the door. C. Place a patch over the client’s affected eye and remove it every 2 hours. D. Remind the client to wash both sides of his or her face. E. Remove clutter to ensure a safe environment. F. Assess the client for memory deficits. B, D, E 14. Which cardiac dysrhythmia does the nurse expect to see when a client with an embolic stroke is placed on a cardiac monitor? A. Sinus bradycardia B. Atrial fibrillation C. Sinus tachycardia D. Ventricular fibrillation B 15. What condition does the nurse suspect when a client reports sudden onset of a severe headache associated with nausea and vomiting, and photophobia? A. Brain tumor B. Ischemic stroke C. Migraine headache D. Cerebral aneurysm D 16. What is the nurse’s best first action when the assistive personnel (AP) reports that a client scheduled for discharge has suddenly developed slurred speech and left-sided weakness? A. Assess the client within 10 minutes for signs and symptoms of brain attack. B. Instruct the client to follow-up with his or her primary care provider tomorrow. C. Call the health care provider to obtain a delay for the discharge. D. Instruct the client to stay in bed and initiate neurologic checks every 2 hours. A 17. Which are the best actions for the nurse to take when caring for a client with a stroke who develops increased intracranial pressure (ICP)? Select all that apply. A. Provide oxygen therapy to prevent hypoxia for clients with oxygen saturation less than 94%. B. Maintain the head in a midline, neutral position to promote venous drainage from the brain. C. Elevate the head of the bed to improve perfusion pressure. D. Cluster nursing care together and then allow the client to rest. E. Avoid sudden and acute hip or neck flexion during positioning. F. Maintain a quiet environment for the client experiencing a headache. A, B, C, E, F 18. Which is the first sign of increased intracranial pressure (ICP) that the nurse will notice in a client at risk for this condition? A. Decrease in level of consciousness B. Increase in systolic blood pressure C. Changes in pupil size and response D. Abnormal posturing of extremities A 19. What is the nurse’s next best action when caring for a client with an epidural hematoma who had decreased level of consciousness, then experienced a period of alert lucidity and was able to talk with the family? A. Document the client’s exact behaviors, comparing them to previous assessments and continue with neurologic assessments every 2 hours. B. Stay with the client and have the charge nurse alert the health care provider because this is an ominous sign for the client. C. Monitor the client for the next 48 hours to 2 weeks because a subacute condition may be slowly developing. D. Instruct the family that the dangerous period has passed but encourage them to leave to avoid tiring the client excessively. B 20. Which drug does the nurse expect will be prescribed to control cerebral vasospasm when a client is diagnosed with subarachnoid hemorrhage (SAH)? A. Phenytoin B. Clopidogrel C. Nimodipine D. Dexamethasone C 21. Which questions are essential for the nurse to ask when getting an accurate history of a client’s traumatic brain injury (TBI)? Select all that apply. A. When, where, and how did the injury occur? B. Did the client lose consciousness? If so, for how long? C. Was drug or alcohol consumption related to the TBI? D. Does the client have a history of seizure disorders? E. Precisely how did the older client fall to cause the TBI? F. Has there been a change in the client’s level of consciousness? A, B, C, D, E, F 22. Which signs and symptoms indicate to the nurse that a client’s traumatic brain injury (TBI) will be diagnosed as mild? Select all that apply. A. Client appears dazed or stunned B. Loss of consciousness (if any occurred) was between 30 to 60 minutes C. Nausea and vomiting D. Headache E. Difficulty with gait or balance F. Sensitivity to noise A, C, D, E, F 23. Why does the health care provider prescribe a ventilator setting to maintain partial pressure of arterial carbon dioxide (Paco2) between 35 and 38 mm Hg for a client with a traumatic brain injury (TBI)? A. Lower levels of arterial carbon dioxide are essential for gas exchange. B. Carbon dioxide is a waste product that must be eliminated from the body. C. Lower levels of arterial carbon dioxide facilitate brain oxygenation. D. Carbon dioxide is a vasodilator that can cause increased intracranial pressure. D 24. What is the nurse’s best interpretation when a client with traumatic brain injury and increased intracranial pressure (ICP) develops severe hypertension with widened pulse pressure and bradycardia? A. The client needs an emergency craniotomy. B. Intravenous antihypertensive drugs will be administered. C. This is a late sign of increased ICP and death is imminent. D. A cardiac monitor should be placed followed by IV atropine. C