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NUR 240 Exam 4 Neuro Iggy Questions
& Answers
- Which clinical finding could help the health care team differentiate a transient ischemic attack from a stroke? a. Patient has a unilateral facial droop. b. Patient has slurred speech. C. Symptoms resolve in 30-60 minutes. d. Electrocardiogram is normal. (Ans- C. Symptoms resolve in 30-60 minutes.
- The nurse is preparing to discharge a patient with transient ischemic attacks. What topics does the nurse include in discharge teaching? Select all that apply. a. Reduction of high blood pressure b. Drug teaching for aspirin or other antiplatelet drug c. Lifestyle changes such as smoking cessation d. Self-care for managing chronic conditions, such as diabetes e. Increased risk for stroke and signs/ symptoms f. Benefits of taking vitamin supplements (Ans- a. Reduction of high blood pressure
b. Drug teaching for aspirin or other antiplatelet drug c. Lifestyle changes such as smoking cessation d. Self-care for managing chronic conditions, such as diabetes e. Increased risk for stroke and signs/ symptoms
- The home health nurse is assessing a patient who had a stroke that affected the right hemisphere. What would the nurse expect to observe? a. Patient is overly anxious and cautious when asked to do a new task. b. Patient is euphoric and smiling but disoriented to person, place, and time. c. Patient is depressed and expresses ongoing worries about the future. d. Patient has a flat affect but is able to answer most questions appropriately. (Ans- b. Patient is euphoric and smiling but disoriented to person, place, and time.
- The nurse is assessing a patient who was brought to the emergency department for altered mental status. In the absence of family members or witnesses to give a history, what does the nurse do to identify two conditions that could mimic emergent neurologic conditions? a. Check skin turgor and perform a bladder scan. b. Check blood glucose and oxygen saturation. C. Observe for jugular vein distention and pitting edema. d. Observe for jaundice and abdominal distention.
C. Loss of language and analytical skills d. Slow and cautious behavior (Ans- a. Poor impulse control
- A stroke patient is at risk for increased intracranial pressure and is receiving oxygen 2 L via nasal cannula. The nurse is reviewing arterial blood gas (ABG) results. Which ABG value is of greatest concern for this patient? a. pH 7. b. Paco2 of 60 mm Hg C. Pao2 of 95 mm Hg d. HCO; of 28 mEq/L (Ans- b. Paco2 of 60 mm Hg
- What is the priority concept for the interdisci- plinary care and treatment of a patient who is suspected of having stroke? a. Pain b. Cognition C. Perfusion d. Sensory perception (Ans- C. Perfusion
- The preferred administration time for intravenous (systemic) fibrinolytic therapy is generally within what time frame of stroke symptom onset?
a. 30-60 minutes b. 3-4.5 hours C. 6-8 hours d. 24-30 hours (Ans- b. 3 - 4.5 hours
- A patient who had a stroke several years ago continues to have the potential for aspiration. Which intervention is best to delegate to unlicensed assistive personnel? a. Monitor the patient for and notify the charge nurse of any occurrence of coughing, choking, or difficulty breathing. b. Elevate the head of the bed and slowly feed small spoonful’s of pudding, pausing between each spoonful. c. Check for swallow reflex by placing index finger and thumb on the Adam's apple and palpating during swallowing. d. Give the patient a glass of water before feeding solid foods, and have oral suction ready at the bedside. (Ans-. b. Elevate the head of the bed and slowly feed small spoonful’s of pudding, pausing between each spoonful.
- A patient is diagnosed with an ischemic stroke. Unlicensed assistive personnel (UAP) reports that the patient's blood pressure (BP) is 150/ mm Hg. The patient's BP prior to the stroke was normally around 120/ mm Hg. What action does the nurse take first? a. Immediately report BP to the health care provider because there is a danger of rebleeding.
- A patient sustained a stroke that affected the right hemisphere of the brain. The patient has visual spatial deficits and deficits of proprioception. After assessing the safety of the patient's home, the home health nurse identifies which environmental feature that represents a potential safety problem for this patient? a. The handrail that borders the bathtub is on the right-hand side. b. The patient's favorite chair faces the front door of the house. C. The patient's bedside table is on the left-hand side of the bed. d. Family has relocated the patient to a ground-floor bedroom. (Ans- a. The handrail that borders the bathtub is on the right-hand side.
- The patient reports a sudden, severe headache, with nausea and vomiting. He says, "This is the worst headache of my life" What condition does the nurse suspect? a. Brain tumor b. Migraine headache C. Cerebral aneurysm d. Ischemic stroke (Ans- C. Cerebral aneurysm
- A patient presents to the advanced stroke center with signs and symptoms of an ischemic stroke. What is the priority factor when considering fibrinolytic therapy? a. Age less than 80 years
b. History of stroke C. Recent surgery d. Time of onset of symptoms (Ans- d. Time of onset of symptoms
- A patient received alteplase for the treatment of ischemic stroke. Following drug administration, the nurse monitors for which adverse effect? a. Severe headache and hypertension b. Hypotension secondary to anaphylaxis c. Respiratory depression and low O2 saturation d. Elevated hematocrit or hemoglobin (Ans- a. Severe headache and hypertension
- The nurse notices that a patient seems to be having trouble swallowing. Which intervention does the nurse employ for this patient? a. Limit the diet to clear liquids given through a straw. b. Withhold food and fluids until swallowing is assessed. C. Monitor the patient's weight and compare trends to baseline. d. Observe the patient while eating and note problematic foods. (Ans- b. Withhold food and fluids until swallowing is assessed.
- The nurse is working on a medical-surgical unit, and unlicensed assistive personnel tells the nurse that a patient who was dressing to go home suddenly developed slurred speech and left-sided weakness. What does the nurse do first?
C. Awareness of potential patient frustration associated with communication d. Avoidance of independent transfers by the patient because of safety issues e. Access to health resources such as publications from the American Heart Association f. Referral to hospice and encouragement of family discussion of advance directives (Ans- a. Need for caregivers to plan for routine respite care and protection of own health b. Evaluation for potential safety risks such as throw rugs or slippery floors C. Awareness of potential patient frustration associated with communication d. Avoidance of independent transfers by the patient because of safety issues e. Access to health resources such as publications from the American Heart Association
- Which patients are at increased risk for stroke? Select all that apply. a. 66-year-old man with diabetes mellitus b. 43-year-old healthy woman who uses oral contraceptives c. 47-year-old woman who exercises regularly d. 35-year-old man with history of multiple transient ischemic attacks e. 25-year-old woman with Bell's palsy
f. 53-year-old man with chronic alcoholism (Ans- a. 66-year-old man with diabetes mellitus b. 43-year-old healthy woman who uses oral contraceptives d. 35-year-old man with history of multiple transient ischemic attacks f. 53-year-old man with chronic alcoholism
- The nurse hears in report that the patient with a stroke had a score of 25 on the National Institutes of Health Stroke Scale when assessed in the emergency department. After therapy and treatment, the most recent score is 20. How does the nurse interpret this information? a. Patient's condition can only be interpreted by trending several scores. b. Patient should be carefully monitored for life-threatening symptoms. C. Patient is possibly a little worse, but change is insignificant. d. Patient is showing improvement and has fewer neurologic deficits. (Ans- d. Patient is showing improvement and has fewer neurologic deficits.
- Which interventions does the nurse use for a patient with a left cerebral hemisphere stroke? Select all that apply. a. Teach the patient to wash both sides of the face. b. Place pictures and familiar objects around the patient. C. Reorient the patient frequently. d. Repeat names of commonly used objects. e. Approach the patient from the affected side.
d. Contacts the health care provider for specific orders about activities related to patient care that might cause increased ICP (Ans- b. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises to hands/fingers
- The nurse is caring for a patient at risk for increased intracranial pressure (ICP). Which sign is most likely to be the first indication of increased ICP? a. Decline of level of consciousness b. Increase in systolic blood pressure c. Change in pupil size and response d. Abnormal posturing of extremities (Ans- a. Decline of level of consciousness
- The stroke patient is prescribed a stool softener every morning. What is the purpose of this drug specific to this patient? a. Stimulates peristaltic action to aid defecation b. Increases frequency of bowel movements C. Decreases fluid and fiber content of stool d. Prevents Valsalva maneuver during defecation (Ans- d. Prevents Valsalva maneuver during defecation
- Which patient handling situation has the greatest potential to lead to a subdural hematoma? a. Sudden vertical elevation of head of the bed of an older patient
b. Log-rolling a patient who has a possible cervical spine injury c. Pulling on the affected flaccid arm of an older stroke patient d. Keeping patient flat and alternating side-lying position every 2 hours (Ans- a. Sudden vertical elevation of head of the bed of an older patient
- The nurse is caring for a patient who has decreased level of consciousness with the medical diagnosis of epidural hematoma. During the shift, the patient becomes lucid and is alert and talking. The family reports this is her baseline mental status. What is the nurse's next action? a. Stay with the patient and have the charge nurse alert the health care provider because this is an ominous sign for the patient. b. Document the patient's exact behaviors, compare to previous nursing entries, and continue the neurologic assessments every 2 hours. C. Point out to the family that the dangerous period has passed, but encourage them to leave so the patient does not become overly fatigued. d. Monitor the patient for the next 48 hours to 2 weeks because a subacute condition be slowly developing. may (Ans- a. Stay with the patient and have the charge nurse alert the health care provider because this is an ominous sign for the patient.
- What are the most common symptoms of stroke? Select all that apply. a. Sudden dizziness, trouble walking, or los of balance or coordination b. Sudden numbness or weakness of the face arm, or leg C. Sudden trouble seeing in one or both eyes d. Sudden shortness of breath or trouble breathing
c. Dexamethasone d. Clopidogrel (Ans- a. Nimodipine
- The home health nurse reads in the patient's chart that he has a mild hemiparesis and ataxia that are residual from a stoke that Based on this occurred several years ago. information, the nurse would assess for functionality and availability of what type of adaptive equipment for this patient? a. Walker and wheelchair for mobility and handrails in the bathroom b. Picture boards, flash cards, or other methods of communication C. Cell phone, computer with internet access, or medical alert device d. Hearing aid, corrective eyeglasses, dentures, and orthotic devices (Ans- a. Walker and wheelchair for mobility and handrails in the bathroom
- The nurse is caring for a patient who had a stroke in the right cerebral hemisphere, and the patient demonstrates unilateral body neglect syndrome. Based on this information, which behavior would the nurse expect to observe? a. Patient uses a pencil and fingers to eat food from the meal tray. b. Patient combs hair on the unaffected side but not on the affected side. C. Patient tells the nurse that bathing and hygiene should be done next month. d. Patient generally looks disheveled and disorganized but is always pleasant. (Ans- b. Patient combs hair on the unaffected side but not on the affected side.
- The neurologist tells the nurse that the stoke patient has some deficits associated with cranial nerves V, VII, IX, X, and XII. Which intervention is the nurse most likely to initiate? a. Prevention of Valsalva maneuver b. Fall precautions C. Prevention of corneal abrasions d. Aspiration precautions (Ans- d. Aspiration precautions
- Following a stroke, a patient demonstrates emotional lability. What is the family most likely to report? a. "He is so depressed all of the time that he hardly even eats anything." b. "He will laugh loudly and then suddenly start crying for apparent reason." C. "He seems really cheerful, almost giddy and euphoric most of the time." d. "He is starting to behave and interact with us like he did before the stroke." (Ans- "He will laugh loudly and then suddenly start crying for no apparent reason."
- The nurse is caring for a patient with an ischemic stroke. Which concept underlies the rationale for placing the patient in a supine position with a low head-of-bed elevation? a. Comfort b. Perfusion C. Gas exchange
a. GCS of 13 with loss of consciousness for 5 minutes b. GCS of 9 with loss of consciousness for 30 minutes c. GCS of 12 with loss of consciousness for 15 minutes d. GCS of 8 with loss of consciousness for 60 minutes (Ans- d. GCS of 8 with loss of consciousness for 60 minutes
- The nurse is assessing a patient who was struck in the head several times with a base- ball bat. There is clear fluid that appears to be leaking from the nose. What action does the nurse take first? a. Ask the patient to gently blow the nose; observe the nasal discharge for blood clots. b. Immediately report the finding to the health care provider and document the observation. C. Place a drop of the fluid on a white absorbent background and look for a yellow halo. d. Assist patient to wipe his nose, but no other action is needed; he has probably been crying. (Ans- C. Place a drop of the fluid on a white absorbent background and look for a yellow halo.
- Which determination must be made first in assessing a patient with traumatic brain injury? a. Presence of spinal injury b. Hypovolemia with hypotension C. Patency of airway
d. Glascow Coma Score (Ans- C. Patency of airway
- A patient is admitted for a closed head injury sustained during a fall down the stairs. The patient has no history of respiratory disease and no apparent respiratory distress. However, the health care provider orders oxygen 2 L via nasal cannula. What is the nurse's best action? a. Use pulse oximeter and apply the oxygen if the saturation level drops below 90%. b. Question the order because oxygen is unnecessary and therefore an extra cost to the patient. C. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure. d. Apply nasal cannula as ordered and wean from oxygen when patient is discharged. (Ans- C. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure.
- The nurse is conducting a presentation to a group of students on the prevention of head injuries. Which statement by a student indicates a need for additional teaching? a. "Drinking, driving, and speeding contribute to the risk for injury." b. "Males are more likely sustain head injury compared to females." c. "Young people are less likely to get injured because of faster reflexes." d. "Following game rules and not goofing around' can prevent injuries." (Ans- c. "Young people are less likely to get injured because of faster reflexes."
