The Brain
A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to?
A. keep the head of the bed flat.
B. elevate the head of the bed to 30 degrees.
C. maintain patient on the left side with the head supported on a pillow.
D. use a continuous-rotation bed to continuously change patient position.
B. elevate the head of the bed to 30 degrees.
Dementia is defined as a
A. syndrome that results only in memory loss.
B. disease associated with abrupt changes in behavior.
C. disease that is always due to reduced blood flow to the brain.
D. syndrome characterized by cognitive dysfunction and loss of memory.
D. syndrome characterized by cognitive dysfunction and loss of memory.
Which patient has the highest risk for having a stroke:
A. 45-year-old Native American with obesity.
B. 65-year-old African American man with hypertension.
C. 35-year-old Asian American woman who smokes.
D. 32-year-old woman taking oral contraceptives.
B. 65-year-old African American man with hypertension.
Name 3 Types of Seizures
1. Generalized-onset
2. Focal-onset
3. Psychogenic Non-epileptic seizures (PNES)
A patient is admitted with a headache, fever, and general malaise. The HCP has asked the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications?
A. Review laboratory results for changes in the white cell count.
B. Give acetaminophen for the headache and fever before the procedure.
C. Notify the provider if signs of increased intracranial pressure are present.
D. Administer antibiotics before the procedure to treat the potential meningitis.
C. Notify the provider if signs of increased intracranial pressure are present.
The nurse is alert to a possible acute subdural hematoma in the patient who
A. has a linear skull feature crossing a major artery.
B. has focal symptoms of brain damage with no recollection of a head injury.
C. develops degreased level of consciousness and a headache within 48 hours of a head injury.
D. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.
C. develops degreased level of consciousness and a headache within 48 hours of a head injury.
Vascular dementia is associated with
A. transient ischemic attacks.
B. viral infection of nerve tissue.
C. cognitive changes from cerebral ischemia.
D. abrupt changes in cognitive function that are irreversible.
C. cognitive changes from cerebral ischemia.
Information provided by the patient that would help distinguish a hemorrhagic stroke from a thrombotic stroke includes
A. sensory changes.
B. history of hypertension.
C. presence of motor weakness.
D. sudden onset of severe headache.
D. sudden onset of severe headache.
When the person senses a seizure is impending (early signs may be noticed hours or even days before seizure is which phase?
A. Prodromal Phase
B. Aural Phase
C. Ictal Phase
D. Postictal Phase
A. Prodromal Phase
The nurse on the clinical unit is assigned to 4 patients. Which patient should she assess first?
A Patient with a soul fracture whose nose is bleeding.
B. A patient with an acute stroke who is confused and whose daughter is present.
C. Patient with meningitis who is suddenly agitated and reporting headache of 10 on a 0 to 10 scale.
D. Patient 2 days postoperative after a craniotomy for a brain tumor who has had continued vomiting.
C. Patient with meningitis who is suddenly agitated and reporting headache of 10 on a 0 to 10 scale.
During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment of
A. airway patency
B. presence of neck injury
C. neurologic status with the Glasgow Coma Scale
D. cerebrospinal fluid leakage from the ears or nose.
A. airway patency
A patient with cognitive impairment would receive a clinical diagnosis of dementia based on
A. CT or MRI
B. brain biopsy
C. electroencephalogram
D. history and cognitive assessment
D. history and cognitive assessment
A patient after a stroke has difficulty finding words and weakness in his right arm. What area of the brain is most likely involved?
A. Brainstem
B. Vertebral artery
C. Left middle cerebral artery
D. Right middle cerebral artery
C. Left middle cerebral artery
The rapid response team is called to the cafeteria. They find a 22-year-old with a known seizure disorder having a tonic-clonic seizure. What actions will be taken during the seizure?
A. Establish IV access.
B. Insert an oral airway.
C. Gently hold the arms to prevent injury.
D. Administer the patient's intranasal midazolam.
E. Turn the person to their side and pad their head.
A. Establish IV access.
D. Administer the patient's intranasal midazolam.
E. Turn the person to their side and pad their head.
A nursing measure that can reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is
A. administering codeine for relief of head and neck pain.
B. controlling fever with prescribed drugs and cooling techniques.
C. maintaining strict bed rest with the head of the bed slightly elevated.
D. keeping the room dark and quiet to minimize environmental stimulation.
B. controlling fever with prescribed drugs and cooling techniques.
A patient suspected of having a brain tumor has memory deficits, visual changes, weakness of right upper and lower extremities, and personality changes. The nurse determines that the tumor is likely located in the
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe
A. frontal lobe
A priority goal of treatment for the patient with Alzheimer disease is to
A. maintain patient safety.
B. maintain or increase body weight.
C. return to a higher level of self-care.
D. enhance functional ability over time.
A. maintain patient safety.
Which test would provide the best initial diagnostic information for a patient who presents to the emergency department with a potential stroke?
A. Non-contrast head CT
B. Cerebral angiography
C. Transcranial dopper ultrasonography
D. Intraarterial digital subtraction angiography
A. Non-contrast head CT
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? (Select all that apply)
A. Loosening restrictive clothing.
B. Restraining the client's limbs.
C. Removing the pillow and raising padded side rails.
D. Positioning the client to the side, if possible, with the head flexed forward.
E. Keeping the curtain around the client and the room door open so that when help arrives, they can quickly enter to assist.
A. Loosening restrictive clothing.
C. Removing the pillow and raising padded side rails.
D. Positioning the client to the side, if possible, with the head flexed forward.
What is the normal range for ICP?
5 - 15 mmHg
Management of a patient with a brain tumor includes (select all that apply)
A. discussing with the patient methods to control inappropriate behavior.
B. using diversion techniques to keep the patient stimulated and motivated.
C. assisting and supporting the family in understanding any changes in behavior.
D. limiting self-care activities until the patient has regained maximum physical functioning.
E. planning for seizure precautions and teaching the patient and the caregiver about anti seizure drugs.
C. assisting and supporting the family in understanding any changes in behavior.
E. planning for seizure precautions and teaching the patient and the caregiver about anti seizure drugs.
Which patient is at the highest risk for developing delirium?
A. A 50-year-old woman with cholecystitis.
B. A 19-year-old man with a fractured femur
C. A 42-year-old woman having an elective total hysterectomy.
D. A 78-year-old man admitted to the medical unit with complications of heart failure.
D. A 78-year-old man admitted to the medical unit with complications of heart failure.
For a patient who is suspected of having a stroke, the most important piece of information that the nurse would obtain is
A. time of the patient's last meal.
B. time at which stroke symptoms first appeared.
C. patient's hypertension history and management.
D. family history of stroke and other cardiovascular diseases.
B. time at which stroke symptoms first appeared.
The time from the first symptom to the end of seizure activity is which phase?
A. Prodromal Phase
B. Aural Phase
C. Ictal Phase
D. Postictal Phase
C. Ictal Phase
What is the normal range of Mean Arterial Pressure (MAP)?
60 - 100