Chapter 35Dysfunction of the Brain: Nursing Management My Nursing Test Banks

Chapter 35Dysfunction of the Brain: Nursing Management

MULTIPLE CHOICE

1.For the client who is at risk for stroke, the most important guideline the nurse should teach is to:

1.

increase drinks with caffeine.

2.

monitor blood pressure.

3.

increase amounts of sodium in the diet.

4.

monitor weight and activity.

ANS: 2

Monitoring weight and activity is important, but the highest priority is monitoring the blood pressure. This is a modifiable risk factor that, when controlled, will decrease the risk of stroke.

PTS:1DIF:Apply

REF:Box 35-1 Modifiable Risk Factors for Stroke Development

2.The family of a client diagnosed with a stroke asks the nurse if this health problem is very common. The nurse should respond that in the United States a person has a stroke every:

1.

40 seconds.

2.

1 minutes.

3.

2 minutes.

4.

5 minutes.

ANS: 1

In the United States, a person has a stroke every 40 seconds, and 700,000 new or recurrent strokes each year. Strokes are the third leading cause of death in the United States behind heart disease and cancer and are the leading cause of long-term disability.

PTS: 1 DIF: Apply REF: Cerebrovascular Accidents or Strokes

3.A client is being evaluated for a stroke. The nurse knows that one of the easiest and most common diagnostic tests used to differentiate between strokes is:

1.

computed tomography (CT).

2.

magnetic resonance imaging (MRI).

3.

electrocardiography (EEG).

4.

positron emission tomography (PET).

ANS: 1

The CT scan is widely available in most hospitals and is an important tool to differentiate between ischemic strokes and hemorrhagic stroke. It is the most common tool used to diagnose a stroke. An MRI is contraindicated in clients with metal implants or pacemakers, and it can exacerbate claustrophobia. An EEG will determine the presence of brain waves, and it is not a diagnostic test for a stroke. A PET scan determines brain tissue functioning but, it will not be able to differentiate between the types of strokes.

PTS:1DIF:AnalyzeREFiagnostic Tests

4.While instructing a client on stroke prevention, the nurse mentions medications that are useful in stroke prevention. The following medications are effective in preventing a stroke, EXCEPT:

1.

anticoagulants.

2.

antiplatelets.

3.

anticholinergics.

4.

neuroprotective agents.

ANS: 3

Although anticholinergic drugs have a variety of uses, stroke prevention is not one of them. All the other medications are used in a variety of ways to help with stroke prevention.

PTS:1DIF:ApplyREFharmacology

5.A client is being seen in the emergency department experiencing symptoms of a stroke. The nurse realizes that the administration of a medication to break clots, such as tPA, should be administered within how many minutes of the client presenting to the emergency department?

1.

30 minutes

2.

60 minutes

3.

90 minutes

4.

120 minutes

ANS: 2

Medications like tPA should be given within 60 minutes of the clients arrival to the emergency department. This is why health care teams must have a plan to deal with stroke clients quickly and efficiently.

PTS: 1 DIF: Analyze REF: Emergency Management

6.The nurse, caring for a client with a traumatic brain injury, realizes that the major cause of these types of injuries is:

1.

guns.

2.

sports.

3.

falls.

4.

motor vehicle crashes.

ANS: 4

Although all are major causes of traumatic brain injury, motor vehicle crashes account for 20% of all traumatic brain injuries. Reasons for motor vehicle accidents causing the most traumatic brain injuries include not wearing seat belts and driving while intoxicated.

PTS: 1 DIF: Analyze REF: Brain Injuries: Etiology

7.A client is diagnosed with a mild brain injury. Which of the following is an example of a mild injury?

1.

Coma

2.

Locked-in syndrome

3.

Vegetative state

4.

Concussion

ANS: 4

A concussion is a mild form of brain trauma, and it accounts for 75% of all brain injuries. A moderate brain injury would result in the loss of consciousness ranging from a few minutes to hours and days or weeks of confusion. Coma, locked-in syndrome, and a vegetative state are all examples of severe brain injury.

PTS: 1 DIF: Analyze REF: Brain Injuries: Pathophysiology

8.The nurse, caring for a client recovering from a traumatic brain injury, knows the client and the family are eligible for specific federal programs because of the:

1.

Health Brain Act.

2.

Associated Brain Act.

3.

Traumatic Brain Injury Act of 2008.

4.

Brain Protection Act.

ANS: 3

The Traumatic Brain Injury Act of 2008 is legislation that provides a framework for prevention of, education about, and research on traumatic brain injuries. The act also supports community living for people who have sustained a traumatic brain injury and their families. The other choices are not programs to assist clients who have sustained a traumatic brain injury or their families.

PTS:1DIF:Analyze

REF: Law in Practice: Traumatic Brain Injury Act of 2008

9.The nurse is planning care for a client diagnosed with increased intracranial pressure after a head injury. Which of the following interventions can be used to reduce increased intracranial pressure?

1.

Administer antibiotics as prescribed.

2.

Keep the head of the bed in the flat position.

3.

Administer corticosteroids and osmotic diuretics as prescribed.

4.

Perform range-of-motion exercises every hour.

ANS: 3

The administration of corticosteroids will decrease the swelling of the brain, and osmotic diuretics will decrease the fluid that is building up. This intervention will decrease the intracranial pressure. Antibiotics do not reduce intracranial pressure. Keeping the head of the bed in the flat position can increase intracranial pressure and not decrease it. Performing range-of-motion exercises every hour will not reduce intracranial pressure.

PTS: 1 DIF: Apply REF: Management of Head Injury

10.Which of the following should be avoided when caring for a client diagnosed with increased intracranial pressure?

1.

Starting an intravenous access line

2.

Administering oxygen

3.

Placing the bed in Trendelenburg

4.

Placing the client on bed rest

ANS: 3

Intravenous access and supplemental oxygen are common interventions in the treatment of increased intracranial pressure. Placing the client on bed rest is a proper safety measure. Placing the bed in Trendelenburg position will increase blood flow to the brain and increase ICP.

PTS: 1 DIF: Apply REF: Management of Head Injury

11.A client is being instructed on treatments available for a newly diagnosed brain tumor. The nurse realizes that this clients treatment could include all of the following EXCEPT:

1.

photo DNA therapy.

2.

radiation.

3.

chemotherapy.

4.

surgery.

ANS: 1

Photo DNA therapy is not a therapy. The other answers are common treatment modalities for patients with brain tumors in addition to photodynamic and adjunctive medication therapy.

PTS: 1 DIF: Analyze REF: Brain Tumors: Planning and Implementation

12.A client diagnosed with an embolic stroke is not a candidate for tPA. The nurse realizes that the client might be eligible for which of the following forms of treatment?

1.

Carotid stenting

2.

Antiarrhythmic medication

3.

Intravenous fluid therapy

4.

Carotid endarterectomy

ANS: 1

In clients who are ineligible for tPA therapy, catheter-based treatment such as stenting may be an option. Carotid endarterectomy is used to prevent a stroke. Antiarrhythmic medication does not prevent a stroke. Intravenous fluid therapy does not prevent a stroke.

PTS: 1 DIF: Analyze REF: Surgery

13.A client diagnosed with a brain tumor is going to receive chemotherapy. The nurse realizes that which of the following medications would most likely be prescribed for this clients treatment?

1.

Carmustine

2.

Digoxin

3.

Aminophylline

4.

Acetaminophen

ANS: 1

One of the biggest obstacles for chemotherapeutic agents when treating brain tumors is selecting a medication that will cross the blood-brain barrier. Carmustine can cross the blood-brain barrier. The other medications are not used as chemotherapy for brain tumors.

PTS: 1 DIF: Analyze REF: Brain Tumors: Chemotherapy

MULTIPLE RESPONSE

1.A client, being tested for a stroke, is not a candidate for tPA. Which of the following would be contraindicated for the use of tPA? (Select all that apply.)

1.

Minor ischemic stroke within 30 days

2.

Glucose level 120 mg/dL

3.

Blood pressure 190/120 mmHg

4.

Lumbar puncture 2 days ago

5.

Stroke onset 5 hours ago

6.

INR 1.0

ANS: 1, 3, 4, 5

Contraindications of tPA to treat an embolic stroke include minor ischemic stroke within the last 30 days, blood pressure greater an 185 mmHg systolic or greater than 110 mmHg diastolic, lumbar puncture within the last 3 days, and onset of stroke greater than 3 hours. Glucose level of 120 mg/dL and INR of 1.0 would not be contraindications for tPA therapy.

PTS:1DIF:Analyze

REF: Table 35-2 Clinical Indications and Contraindications for tPA in Stroke Patients

2.The nurse, planning care for a client recovering from a traumatic brain injury, is including interventions to prevent sympathetic storming. Which of the following should be included in this clients plan of care? (Select all that apply.)

1.

Medicate for pain prior to conducting a painful procedure.

2.

Elevated blood pressure indicates a sympathetic storm is ending.

3.

Continue suctioning until the clients heart rate is greater than 100 beats per minute.

4.

Cardiac arrhythmias indicate a drop in intracranial pressure.

5.

Provide beta-blockers as prescribed with symptoms of sympathetic storm.

6.

If symptoms of sympathetic storm do not appear within 24 hours, the client will not develop this health problem.

ANS: 1, 5

The nurse should medicate the client for pain prior to conducting a painful procedure and provide beta-blockers as prescribed with symptoms of a sympathetic storm. An elevated blood pressure is a symptom of sympathetic storm. An elevated heart rate is a symptom of sympathetic storming. Cardiac arrhythmias are also a symptom of a sympathetic storm and do not indicate a drop in intracranial pressure. Symptoms of sympathetic storming can occur within 24 hours after a traumatic brain injury and can reoccur periodically during the recovery process.

PTS: 1 DIF: Apply REF: Red Flag: Sympathetic Storming

3.The nurse is providing discharge instructions to a client recovering from a traumatic brain injury. Which of the following should be included in these instructions? (Select all that apply.)

1.

Return to a full schedule of work as soon as possible.

2.

Acquire medical clearance prior to returning to work that uses heavy equipment.

3.

Avoid the use of helmets.

4.

Limit the amount of alcoholic beverages.

5.

Avoid all illicit drug use.

6.

Eat a well-balanced diet.

ANS: 2, 5, 6

Discharge instructions for a client recovering from a traumatic brain injury should include: medical clearance is needed prior to returning to work that uses heavy equipment; avoid all illicit drug use; and eat a well-balanced diet. The client should be cautioned to avoid returning to a full schedule of work as soon as possible. The client should be encouraged to use helmets or other safety equipment to protect the head. The clients should be instructed to avoid all alcoholic beverages.

PTS:1DIF:Apply

REF: Patient Playbook: Education Topics for a Patient with a Brain Injury

4.A client asks the nurse to explain symptoms that would indicate the presence of a brain tumor. Which of the following should the nurse respond to this client? (Select all that apply.)

1.

There are no symptoms specific to a brain tumor.

2.

Dizziness is a common symptom.

3.

Ringing or buzzing in the ears can occur.

4.

Seizures may occur.

5.

A headache that gets worse in the afternoon is specific to a brain tumor..

6.

A headache is usually experienced by 50% of all people diagnosed with a brain tumor.

ANS: 2, 3, 4, 6

Symptoms of a brain tumor include dizziness, ringing or buzzing in the ears, seizures, and a headache. The headache of a brain tumor is usually worse in the morning and not the afternoon. There are symptoms associated with a brain tumor.

PTS:1DIF:Apply

REF: Brain Tumors: Assessment with Clinical Manifestations

5.The nurse is instructing a client diagnosed with a brain tumor on symptoms to immediately report to her physician. Which of the following should be included in these instructions? (Select all that apply.)

1.

New onset of seizures

2.

One-sided weakness

3.

Loss of balance

4.

Problems with vision

5.

Inability to talk

6.

Loss of appetite

ANS: 1, 2, 3, 4, 5

Brain tumor symptoms that require immediate attention include new onset of seizures, slow progressing hemiparesis, gait or balance disturbances, visual problems, hearing loss, and aphasia. Loss of appetite is not a brain tumor symptom.

PTS:1DIF:Apply

REF: Red Flag: Brain Tumor Symptoms that Require Immediate Attention

6.The nurse, caring for a client diagnosed with a brain tumor, is planning interventions to assist with swallowing and prevent aspiration. Which of the following would be appropriate for this client? (Select all that apply.)

1.

Instruct the client to tuck the chin with each swallow.

2.

Instruct the client to turn the head toward the strong side to swallow.

3.

Instruct the client to turn the head toward the weak side to swallow.

4.

Instruct the client to hold the breath while swallowing.

5.

Instruct the client to eat in a reclining position.

6.

Instruct the client to sit in an upright position when eating.

ANS: 1, 3, 4, 6

Interventions to assist a client with swallowing and prevent aspiration include have the client tuck the chin with each swallow, turn the head to the weak side to swallow, hold the breath while swallowing, and sitting in an upright position to swallow. The client should not be instructed to turn the head toward the strong side to swallow or to eat in a reclining position.

PTS: 1 DIF: Apply REF: Brain Tumors: Planning and Implementation

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