Stroke
This type of stroke occurs when a blood clot or thrombus blocks blood flow to a part of the brain, leading to ischemia.
What is an ischemic stroke?
(Rationale: Ischemic strokes account for about 87% of strokes and result from obstruction of cerebral blood flow.)
This type of TBI occurs when the brain impacts the inside of the skull without penetration, often from a fall or car accident, causing bruising and swelling.
What is a closed (blunt) traumatic brain injury?
(Rationale: Closed TBIs involve brain injury without an open wound; contusions and concussions are common examples.)
This term describes a set of physical, cognitive, and emotional symptoms that persist for weeks or months after a mild traumatic brain injury or concussion.
What is post-concussion syndrome (PCS)?
(Rationale: PCS occurs after a concussion when symptoms like headache, dizziness, and cognitive changes persist beyond the expected recovery period.)
This term describes inflammation of the protective membranes covering the brain and spinal cord, often caused by bacterial or viral infection.
What is meningitis?
(Rationale: Meningitis can be bacterial, viral, or fungal, and inflammation can lead to increased intracranial pressure and neurological complications.)
This condition is characterized by an abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles of the brain, leading to increased intracranial pressure.
What is hydrocephalus?
(Rationale: Hydrocephalus can be congenital or acquired, caused by obstruction, poor absorption, or overproduction of CSF.)
A patient suddenly develops slurred speech, right-sided weakness, and facial droop. The nurse recognizes these as classic signs of this neurological event.
What is a stroke (cerebrovascular accident)?
(Rationale: Sudden focal neurological deficits, often one-sided, are hallmark signs of a stroke.)
A patient with a TBI exhibits unequal pupils, confusion, and a declining Glasgow Coma Scale score. The nurse recognizes these as early signs of this serious complication.
What is increased intracranial pressure (ICP)?
(Rationale: Changes in LOC, pupillary response, and motor function are early indicators of rising ICP.)
A patient complains of persistent headaches, dizziness, irritability, and difficulty concentrating several weeks after a mild head injury. These symptoms are classic manifestations of this condition.
What is post-concussion syndrome?
(Rationale: PCS presents with a constellation of physical, cognitive, and emotional symptoms following a concussion.)
A patient presents with fever, headache, neck stiffness, and photophobia. These are classic manifestations of this neurological condition.
What is meningitis?
(Rationale: The triad of fever, neck stiffness, and headache is highly suggestive of meningitis, and photophobia is also common.)
An infant presents with rapid head growth, bulging fontanel, irritability, and vomiting. These findings are indicative of this condition.
What is hydrocephalus?
(Rationale: Infants show signs of increased ICP due to the open fontanels, which allow the head to expand.)
After a stroke, a patient develops increased intracranial pressure with vomiting, headache, and altered LOC. The nurse recognizes this as a serious complication called this.
What is cerebral edema leading to increased intracranial pressure (ICP)?
(Rationale: Stroke can cause swelling and hemorrhagic conversion, increasing ICP and risking herniation.)
After a severe TBI, a patient develops loss of coordination, slurred speech, and difficulty swallowing. These symptoms are indicative of injury to this part of the brain.
What is the cerebellum or brainstem?
(Rationale: The cerebellum controls coordination; the brainstem controls vital functions; injury here can result in severe deficits.)
When assessing a patient for post-concussion syndrome, the nurse should prioritize evaluation of these three domains.
What are neurological function, cognitive status, and emotional/behavioral changes?
(Rationale: PCS affects multiple domains, so a comprehensive assessment ensures early recognition and management.)
The nurse anticipates that a patient suspected of meningitis will undergo this definitive diagnostic test.
What is a lumbar puncture (spinal tap) for cerebrospinal fluid analysis?”
(Rationale: CSF analysis differentiates bacterial from viral meningitis and guides treatment.)
An adult patient reports gait disturbance, urinary incontinence, and cognitive decline. The nurse recognizes these as hallmark signs of this type of hydrocephalus.
What is normal pressure hydrocephalus (NPH)?
(Rationale: NPH develops gradually in adults and presents with the triad of gait disturbance, urinary incontinence, and dementia-like cognitive changes.)
The nurse’s priority action for a patient presenting with an acute ischemic stroke within the hospital is this.
What is assessing ABCs, performing a rapid neurologic assessment (NIH Stroke Scale), and notifying the stroke team?
(Rationale: Early recognition and rapid response are critical for eligibility for thrombolytic therapy.)
The nurse caring for a patient with a severe TBI knows the priority nursing intervention to prevent secondary brain injury is this.
What is maintaining airway, ensuring adequate oxygenation, and monitoring for signs of increased ICP?
(Rationale: Secondary brain injury can result from hypoxia, hypotension, or increased ICP; these must be prevented to improve outcomes.)
The nurse educates a patient recovering from a concussion that these measures can help reduce symptoms of post-concussion syndrome.
What are getting adequate rest, gradually resuming activities, avoiding alcohol and sedatives, and monitoring for worsening symptoms?
(Rationale: Education on activity modification and symptom monitoring promotes recovery and prevents complications.)
For a patient diagnosed with bacterial meningitis, the nurse prioritizes this intervention.
What is initiating prompt IV antibiotic therapy and implementing droplet precautions?
(Rationale: Early antibiotics improve outcomes; droplet precautions prevent spread to others.)
The nurse cares for a patient post-ventriculoperitoneal (VP) shunt placement for hydrocephalus. The priority nursing action is this.
What is monitoring for signs of increased ICP, infection, and proper shunt function?
(Rationale: VP shunts can malfunction or become infected; early recognition of complications is critical.)
A patient asks how to reduce the risk of stroke. The nurse correctly identifies this modifiable risk factor.
What is controlling hypertension, managing diabetes, quitting smoking, and maintaining a healthy diet?
(Rationale: Modifiable risk factors account for a significant portion of stroke prevention.)
The nurse educates a family that the most common cause of traumatic brain injury in adults is this.
What are motor vehicle accidents (MVAs)?
(Rationale: MVAs, falls, and violence are leading causes of TBI; prevention strategies include seat belts, helmets, and fall precautions.)
The nurse instructs a patient with PCS to seek immediate medical attention if they experience this symptom.
What is sudden worsening headache, repeated vomiting, vision changes, weakness, or confusion?
(Rationale: These may indicate a more serious intracranial complication such as hemorrhage or increased ICP.)
A patient with meningitis becomes confused, lethargic, and develops a bulging fontanel (if infant) or severe headache (if adult). The nurse recognizes these as signs of this serious complication.
What is increased intracranial pressure (ICP)?
(Rationale: Inflammation can cause cerebral edema, leading to ICP elevation, which can be life-threatening.)
A patient with a VP shunt develops fever, abdominal pain, and erythema along the shunt tract. The nurse recognizes these as signs of this serious complication.
What is shunt infection?
(Rationale: Shunt infections can lead to meningitis, sepsis, or worsening hydrocephalus; prompt intervention is required.)