Stroke
A patient is admitted with uncontrolled atrial fibrillation. The patient’s medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?
Ischemic embolism
If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?
Restlessness: Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.
What kind of precautions are meningitis patients placed in?
Droplet
Which patient below is at MOST risk for developing a condition called autonomic dysreflexia?
A 15-year-old female patient with a spinal cord injury at C7.
Which of the following are not a treatment for Thyroid Storm?
A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected?
The temporal lobe is responsible for hearing, learning, and feelings/emotions.
What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?
Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased.
What type of meningitis has clear cerebrospinal fluid, is less worrisome, and more common.
Viral
Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action?
Assess BP. The patient is at risk for developing autonomic dysreflexia because of their spinal cord injury at T3 (remember patients who have a SCI at T6 or higher are at MOST risk). If a patient with this type of injury states they have a headache, the nurse should NEXT assess the patient's blood pressure. If it is elevated, the nurse would take measures to check the bladder (a bladder issue is the most common cause of AD), bowel, and skin for breakdown.
A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment?
You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as:
Hemianopia
You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is:
60-100 mmHg
What are the immediate interventions of the nurse during a witnessed seizure of the patient?
Airway
Time it
IV access/Meds
Keep Patient Safe
The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes. T or F
FALSE….the statement should say: The sympathetic (NOT parasympathetic) nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.
A patient is complaining of chest pain. On the bedside cardiac monitor you observe pronounce T-wave inversion. You obtain the patient's vital signs and find the following: Blood pressure 190/98, HR 110, oxygen saturation 96% on room air, and respiratory rate 20. Select-all-that-apply in regards to the MOST IMPORTANT nursing interventions you will provide based on the patient’s current status:
The answers are A, D, E, G, and H.
In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered?
tPA dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!
BP 200/60, HR 50, RR 8
These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.
A patient has experienced a brain injury. You note that written in the progress notes the physician says the patient has a GCS 10. What is the level of brain injury in this patient?
The answer is B. GCS Scores can range from 3 to 15. Here is how a brain injury can be classified based on a GCS score: 3-8: severe brain injury, 9-12: moderate brain injury, 13-15: mild brain injury
A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT?
Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves. The sympathetic and parasympathetic systems are, in a way, balancing each other out when it comes to the heart rate. The sympathetic system increases it, while the parasympathetic decreases it. If the sympathetic system isn’t working the way it should, it can NOT oppose the parasympathetic system….which will take over and lead to bradycardia.
A patient with acute renal injury has a GFR (glomerular filtration rate) of 40 mL/min. Which signs and symptoms below may this patient present with? Select all that apply:
The glomerular filtration rate indicates how well the glomerulus is filtering the blood. A normal GFR tends to be 90 mL/min or higher. A GFR of 40 mL/min indicates that the kidney's ability to filter the blood is decreased. Therefore, the kidneys will be unable to remove waste and excessive water from the blood...hence hypervolemia and an increased BUN level will present in this patient. The patient will experience HYPERkalemia (not hypo) because the kidneys are unable to remove potassium from the blood. In addition, an INCREASED creatinine level (not decreased) will present because the kidneys cannot remove excessive waste products, such as creatinine.
Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke?
Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.
During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as:
Decerebrate posturing
You're maintaining an external ventricular drain. The ICP readings should be?
5 to 15 mmHg
You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock?
A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply:
A. Increase albumin levels
B. Ascites
C. Splenomegaly
D. Fluid volume deficient
E. Esophageal varices
B, C, and E. Portal Hypertension is where the portal vein becomes narrow due to scar tissue in the liver, which is restricting the flow of blood to the liver. Therefore, pressure becomes increased in the portal vein and affects the organs connected via the vein to the liver. The patient may experience ascites, enlarged spleen "splenomegaly", and esophageal varices etc.