Question 1

A client with a stroke has damage to Broca's area.What intervention to promote communication is best for this client?

Accepted Answer

Damage to Broca's area often leads to expressive aphasia,wherein the client can understand what is said but cannot express thoughts verbally.In some instances the client can write.The nurse should assess to see if that ability is intact."Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly.Reinforcing speech therapy exercises is good for all clients with communication difficulties.Neologisms are made-up "words" often used by clients with sensory aphasia.

Question 2

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia.What action by the nurse is most appropriate for this client?

Accepted Answer

This condition is blindness on the same side of both eyes.The client must turn his or her head to see the entire visual field.The client may not see all the food on the tray,so the nurse rotates it so uneaten food is now within the visual field.This condition is not related to bladder function,difficulty swallowing,or lack of trunk control.

Question 3

A client has a traumatic brain injury.The nurse assesses the following: pulse change from 82 to 60 beats/min,pulse pressure increase from 26 to 40 mm Hg,and respiratory irregularities.What action by the nurse takes priority?

Accepted Answer

These manifestations indicate Cushing's syndrome,a potentially life-threatening increase in intracranial pressure (ICP),which is an emergency.Immediate medical attention is necessary,so the nurse notifies the provider or the Rapid Response Team.Increasing fluids would increase the ICP.The client does not need a breathing treatment or pain medication.

Question 4

A client had an embolic stroke and is having an echocardiogram.When the client asks why the provider ordered "a test on my heart," how should the nurse respond?

Accepted Answer

An embolic stroke is caused when blood clots travel from one area of the body to the brain.The most common source of the clots is the heart.The other statements are inaccurate.

Question 5

A nurse assesses a client with the National Institutes of Health (NIH)Stroke Scale and determines the client's score to be 36.How should the nurse plan care for this client?

Accepted Answer

This client has severe neurologic deficits and will need near-total care.Safety precautions are important but do not give a full picture of the client's dependence.The client will need more than cuing to complete tasks.A home discharge may be possible,but this does not help the nurse plan care for a very dependent client.

Question 6

The nurse is caring for four clients with traumatic brain injuries.Which client should the nurse assess first?

Accepted Answer

A fever is a poor prognostic indicator in clients with brain injuries.The nurse should see this client first.A Glasgow Coma Scale score of 12,a PaCO₂ of 36,and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

Question 7

A client with a traumatic brain injury is agitated and fighting the ventilator.What drug should the nurse prepare to administer?

Accepted Answer

Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury.Carbamazepine is an antiseizure drug.Diazepam is a benzodiazepine.Mannitol is an osmotic diuretic.

Question 8

A client had an embolectomy for an arteriovenous malformation (AVM).The client is now reporting a severe headache and has vomited.What action by the nurse takes priority?

Accepted Answer

This client may be experiencing a rebleed from the AVM.The most important action is to call the Rapid Response Team as this is an emergency.The nurse can assess vital signs while someone else notifies the Team,but getting immediate medical attention is the priority.Administering pain medication may not be warranted if the client must return to surgery.The optimal position for the client with an AVM has not been determined,but calling the Rapid Response Team takes priority over positioning.

Question 9

A nurse is caring for four clients in the neurologic intensive care unit.After receiving the hand-off report,which client should the nurse see first?

Accepted Answer

A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first.An improvement in the score is a good sign.Amnesia is an expected finding with brain injuries,so this client is lower priority.The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

Question 10

A client in the intensive care unit is scheduled for a lumbar puncture (LP)today.On assessment,the nurse finds the client breathing irregularly with one pupil fixed and dilated.What action by the nurse is best?

Accepted Answer

This client is exhibiting signs of increased intracranial pressure.The nurse should notify the provider immediately because performing the LP now could lead to herniation.Informed consent is needed for an LP,but this is not the priority.Documentation should be thorough,but again this is not the priority.The preprocedure sedation (or other preprocedure medications)should not be given as the LP will most likely be canceled.

Question 11

A client who had a severe traumatic brain injury is being discharged home,where the spouse will be a full-time caregiver.What statement by the spouse would lead the nurse to provide further education on home care?

Accepted Answer

This caregiver has unrealistic expectations about being able to do everything without help.Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals.Hoping for improvement over time is also realistic,especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook.

Question 12

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating.What nursing assessment best indicates that a priority goal for this problem has been met?

Accepted Answer

Impaired swallowing can lead to aspiration,so the priority goal for this problem is no aspiration.Clear lung sounds is the best indicator that aspiration has not occurred.Choosing menu items is not related to this problem.Eating meals does not indicate the client is not still aspirating.A weight gain indicates improved nutrition but still does not show a lack of aspiration.

Question 13

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury.The client's spouse is very frustrated,stating that the client's personality has changed and the situation is intolerable.What action by the nurse is best?

Accepted Answer

Personality and behavior often change permanently after head injury.The nurse should explain this to the spouse.Asking the client about his or her behavior isn't useful because the client probably cannot help it.A referral might be a good idea,but the nurse needs to do something in addition to just referring the couple.Telling the spouse to learn to cope belittles the spouse's concerns and feelings.

Question 14

A client is in the emergency department reporting a brief episode during which he was dizzy,unable to speak,and felt like his legs were very heavy.Currently the client's neurologic examination is normal.About what drug should the nurse plan to teach the client?

Accepted Answer

This client's manifestations are consistent with a transient ischemic attack,and the client would be prescribed aspirin or clopidogrel on discharge.Alteplase is used for ischemic stroke.Heparin and mannitol are not used for this condition.

Question 15

A nurse is caring for four clients who might be brain dead.Which client would best meet the criteria to allow assessment of brain death?

Accepted Answer

In order to determine brain death,clients must meet four criteria: 1)coma from a known cause,2)normal or near-normal core temperature,3)normal systolic blood pressure,and 4)at least one neurologic examination.The client who was in the car crash meets two of these criteria.The clients with the lower temperature and lower blood pressure have only one of these criteria.There is no data to support assessment of brain death in the client found by the hunter.

Question 16

A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg.Based on the client's cerebral perfusion pressure,what should the nurse anticipate for this client?

Accepted Answer

The cerebral perfusion pressure (CPP)is the intracranial pressure subtracted from the mean arterial pressure: in this case,60 - 20 = 40.For optimal outcomes,CPP should be at least 70 mm Hg.This client has very low CPP,which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive.This data does not indicate impending brain herniation or complete recovery.

Question 17

After a craniotomy,the nurse assesses the client and finds dry,sticky mucous membranes and restlessness.The client has IV fluids running at 75 mL/hr.What action by the nurse is best?

Accepted Answer

This client has manifestations of hypernatremia,which is a possible complication after craniotomy.The nurse should assess the client's serum sodium level.Magnesium level is not related.The nurse does not independently increase the rate of the IV infusion.Providing oral care is also a good option but does not take priority over assessing laboratory results.

Question 18

A student nurse is preparing morning medications for a client who had a stroke.The student plans to hold the docusate sodium (Colace)because the client had a large stool earlier.What action by the supervising nurse is best?

Accepted Answer

Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated.The supervising nurse should instruct the student to administer the docusate.The other options are not appropriate.The medication could be held for diarrhea.

Question 19

A client is being prepared for a mechanical embolectomy.What action by the nurse takes priority?

Accepted Answer

For this invasive procedure,the client needs to give informed consent.The nurse ensures that this is on the chart prior to the procedure beginning.Fibrinolytics are not used.A neurologic assessment and medication review are important,but the consent is the priority.

Question 20

A client with a stroke is being evaluated for fibrinolytic therapy.What information from the client or family is most important for the nurse to obtain?

Accepted Answer

The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours,so the exact time of symptom onset is the most important information for this client.The other information is not as critical.

Quiz 45: Care of Critically Ill Patients with Neurologic Problems