RNUR 238 EXAM 4 QUESTIONS & ANSWERS
What is the worst score on the GCS - Answer -3
What layer protects the brain and spinal cord - Answer -Meninges
How synapse happen - Answer -via chemical and electrical signals ( action potential)
parasympathetic nervous system - Answer -rest and digest
What nerve does the romberg test-test - Answer -cranial nerve 8
Pt. teaching for CT scan - Answer -must keep head completely still for imaging
MRI uses what type of field - Answer -Magnetic field
A SPECT is contraindicated in who? - Answer -pregnant woman
Cerebral Angiography involves a catheter inserted into _______________ artery (groin
stick) so monitoring for s/s of _______ or _________ after - Answer -femoral
bleeding or hematoma
Since dye is used in Cerebral Angiography monitor __________________ pre and post
procedure - Answer -kidney function (BUN/creatinine)
EEG measures _______________ activity of the brain - Answer -electrical
Eating is allowed prior to EEG, but no________ - Answer -caffeine including chocolate
or decaf. NO coffee, tea, chocolate chip cookies
lumbar puncture fluid should be - Answer -clear and colorless
How long should a lumbar puncture pt. lay on their side_____________ and what does
it prevent? - Answer -2 hrs
spinal headaches- allows site to heal and close
what is the # 1 s/s complication of lumbar puncture - Answer -spinal headaches
introducing the needle into the skin during lumbar puncture causes risk for? - Answer -
infection
What position should the pt. lay in to obtain CSF - Answer -C shape allows them to get
in between the vertebra easier
, what is the outer protective layer of the cell body that is covering the axon - Answer -
Myelin sheath
Regular oral hygiene is an essential intervention for the client who has had a stroke.
Which of the following nursing measures is inappropriate when providing oral hygiene?
A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the client's mouth with a padded tongue blade.
D. Cleaning the client's mouth and teeth with a toothbrush. - Answer -A. Placing the
client on the back with a small pillow under the head.
A 78-year-old client is admitted to the emergency department with numbness and
weakness of the left arm and slurred speech. Which nursing intervention is a priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation. - Answer -C. Schedule
for A STAT computer tomography (CT) scan of the head
A client arrives in the emergency department with an ischemic stroke and receives
tissue plasminogen activator (t-PA) administration. Which is the priority nursing
assessment?
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures - Answer -A. Time of onset of current stroke
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal
is to control the client's:
A. Pulse
B. Respirations
C. Blood pressure
D. Temperature - Answer -C. Blood pressure
Controlling the blood pressure is critical because an intracerebral hemorrhage is the
major adverse effect of thrombolytic therapy. Blood pressure should be maintained
according to the physician and is specific to the client's ischemic tissue needs and risks
of bleeding from treatment. Other vital signs are monitored, but the priority is blood
pressure.
What is a priority nursing assessment in the first 24 hours after admission of the client
with a thrombotic stroke?
What is the worst score on the GCS - Answer -3
What layer protects the brain and spinal cord - Answer -Meninges
How synapse happen - Answer -via chemical and electrical signals ( action potential)
parasympathetic nervous system - Answer -rest and digest
What nerve does the romberg test-test - Answer -cranial nerve 8
Pt. teaching for CT scan - Answer -must keep head completely still for imaging
MRI uses what type of field - Answer -Magnetic field
A SPECT is contraindicated in who? - Answer -pregnant woman
Cerebral Angiography involves a catheter inserted into _______________ artery (groin
stick) so monitoring for s/s of _______ or _________ after - Answer -femoral
bleeding or hematoma
Since dye is used in Cerebral Angiography monitor __________________ pre and post
procedure - Answer -kidney function (BUN/creatinine)
EEG measures _______________ activity of the brain - Answer -electrical
Eating is allowed prior to EEG, but no________ - Answer -caffeine including chocolate
or decaf. NO coffee, tea, chocolate chip cookies
lumbar puncture fluid should be - Answer -clear and colorless
How long should a lumbar puncture pt. lay on their side_____________ and what does
it prevent? - Answer -2 hrs
spinal headaches- allows site to heal and close
what is the # 1 s/s complication of lumbar puncture - Answer -spinal headaches
introducing the needle into the skin during lumbar puncture causes risk for? - Answer -
infection
What position should the pt. lay in to obtain CSF - Answer -C shape allows them to get
in between the vertebra easier
, what is the outer protective layer of the cell body that is covering the axon - Answer -
Myelin sheath
Regular oral hygiene is an essential intervention for the client who has had a stroke.
Which of the following nursing measures is inappropriate when providing oral hygiene?
A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the client's mouth with a padded tongue blade.
D. Cleaning the client's mouth and teeth with a toothbrush. - Answer -A. Placing the
client on the back with a small pillow under the head.
A 78-year-old client is admitted to the emergency department with numbness and
weakness of the left arm and slurred speech. Which nursing intervention is a priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation. - Answer -C. Schedule
for A STAT computer tomography (CT) scan of the head
A client arrives in the emergency department with an ischemic stroke and receives
tissue plasminogen activator (t-PA) administration. Which is the priority nursing
assessment?
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures - Answer -A. Time of onset of current stroke
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal
is to control the client's:
A. Pulse
B. Respirations
C. Blood pressure
D. Temperature - Answer -C. Blood pressure
Controlling the blood pressure is critical because an intracerebral hemorrhage is the
major adverse effect of thrombolytic therapy. Blood pressure should be maintained
according to the physician and is specific to the client's ischemic tissue needs and risks
of bleeding from treatment. Other vital signs are monitored, but the priority is blood
pressure.
What is a priority nursing assessment in the first 24 hours after admission of the client
with a thrombotic stroke?
