Question 1

A client with a stroke has damage to Broca's area.What intervention to promote communication is best for this client?

Accepted Answer

A)  Assess whether or not the client can write. 
B)  Communicate using "yes-or-no" questions. 
C)  Reinforce speech therapy exercises. 
D)  Remind the client not to use neologisms.

Question 2

The nurse working in the emergency department assesses a client who has symptoms of stroke.For what modifiable risk factors should the nurse assess? (Select all that apply.)

Accepted Answer

A)  Alcohol intake 
B)  Diabetes 
C)  High-fat diet 
D)  Obesity 
E)  Smoking

Question 3

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia.What action by the nurse is most appropriate for this client?

Accepted Answer

A)  Assess for bladder retention and/or incontinence. 
B)  Listen to the client's lungs after eating or drinking. 
C)  Prop the client's right side up when sitting in a chair. 
D)  Rotate the client's meal tray when the client stops eating.

Question 4

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating.What nursing assessment best indicates that a priority goal for this problem has been met?

Accepted Answer

A)  Chooses preferred items from the menu 
B)  Eats 75% to 100% of all meals and snacks 
C)  Has clear lung sounds on auscultation 
D)  Gains 2 pounds after 1 week

Question 5

A client is being prepared for a mechanical embolectomy.What action by the nurse takes priority?

Accepted Answer

A)  Assess for contraindications to fibrinolytics. 
B)  Ensure that informed consent is on the chart. 
C)  Perform a full neurologic assessment. 
D)  Review the client's medication lists.

Question 6

A nurse is providing community screening for risk factors associated with stroke.Which client would the nurse identify as being at highest risk for a stroke?

Accepted Answer

A)  A 27-year-old heavy cocaine user 
B)  A 30-year-old who drinks a beer a day 
C)  A 40-year-old who uses seasonal antihistamines 
D)  A 65-year-old who is active and on no medications

Question 7

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI).The nurse notes the presence of an aneurysm clip in the client's record.What action by the nurse is best?

Accepted Answer

A)  Ask the client how long ago the clip was placed. 
B)  Have the client sign an informed consent form. 
C)  Inform the provider about the aneurysm clip. 
D)  Reschedule the client for computed tomography.

Question 8

A client is in the emergency department reporting a brief episode during which he was dizzy,unable to speak,and felt like his legs were very heavy.Currently the client's neurologic examination is normal.About what drug should the nurse plan to teach the client?

Accepted Answer

A)  Alteplase (Activase) 
B)  Clopidogrel (Plavix) 
C)  Heparin sodium 
D)  Mannitol (Osmitrol)

Question 9

A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activator (t-PA)alteplase (Activase).The client weighs 146 pounds.How much medication will this client receive? (Record your answer using a whole number.)_____ mg

Accepted Answer

The answer of A client in the emergency department is...

Question 10

The nurse assesses a client's Glasgow Coma Scale (GCS)score and determines it to be 12 (a 4 in each category).What care should the nurse anticipate for this client?

Accepted Answer

A)  Can ambulate independently 
B)  May have trouble swallowing 
C)  Needs frequent re-orientation 
D)  Will need near-total care

Question 11

A nurse has applied to work at a hospital that has National Stroke Center designation.The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care.What do these Core Measures include? (Select all that apply.)

Accepted Answer

A)  Discharging the client on a statin medication 
B)  Providing the client with comprehensive therapies 
C)  Meeting goals for nutrition within 1 week 
D)  Providing and charting stroke education 
E)  Preventing venous thromboembolism

Question 12

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury.What information obtained from the client represents a possible barrier to self-management? (Select all that apply.)

Accepted Answer

A)  Does not want to purchase a thermometer 
B)  Is allergic to acetaminophen (Tylenol) 
C)  Laughing, says "Strenuous? What's that?" 
D)  Lives alone and is new in town with no friends 
E)  Plans to have a beer and go to bed once home

Question 13

A nurse is caring for a client after a stroke.What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Accepted Answer

A)  Assess neurologic status with the Glasgow Coma Scale. 
B)  Check and document oxygen saturation every 1 to 2 hours. 
C)  Cluster client care to allow periods of uninterrupted rest. 
D)  Elevate the head of the bed to 45 degrees to prevent aspiration. 
E)  Position the client supine with the head in a neutral midline position.

Question 14

A client in the emergency department is having a stroke.The client weighs 225 pounds.After the initial bolus of t-Pa,at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.)____ mL/hr

Accepted Answer

The answer of A client in the emergency department is...

Question 15

After a craniotomy,the nurse assesses the client and finds dry,sticky mucous membranes and restlessness.The client has IV fluids running at 75 mL/hr.What action by the nurse is best?

Accepted Answer

A)  Assess the client's magnesium level. 
B)  Assess the client's sodium level. 
C)  Increase the rate of the IV infusion. 
D)  Provide oral care every hour.

Question 16

A client has an intraventricular catheter.What action by the nurse takes priority?

Accepted Answer

A)  Document intracranial pressure readings. 
B)  Perform hand hygiene before client care. 
C)  Measure intracranial pressure per hospital policy. 
D)  Teach the client and family about the device.

Question 17

A nursing student studying traumatic brain injuries (TBIs)should recognize which facts about these disorders? (Select all that apply.)

Accepted Answer

A)  A client with a moderate trauma may need hospitalization. 
B)  A Glasgow Coma Scale score of 10 indicates a mild brain injury. 
C)  Only open head injuries can cause a severe TBI. 
D)  A client with a Glasgow Coma Scale score of 3 has severe TBI. 
E)  The terms "mild TBI" and "concussion" have similar meanings.

Question 18

A client with a traumatic brain injury is agitated and fighting the ventilator.What drug should the nurse prepare to administer?

Accepted Answer

A)  Carbamazepine (Tegretol) 
B)  Dexmedetomidine (Precedex) 
C)  Diazepam (Valium) 
D)  Mannitol (Osmitrol)

Question 19

After a stroke,a client has ataxia.What intervention is most appropriate to include on the client's plan of care?

Accepted Answer

A)  Ambulate only with a gait belt. 
B)  Encourage double swallowing. 
C)  Monitor lung sounds after eating. 
D)  Perform post-void residuals.

Question 20

A nurse is caring for four clients in the neurologic intensive care unit.After receiving the hand-off report,which client should the nurse see first?

Accepted Answer

A)  Client with a Glasgow Coma Scale score that was 10 and is now is 8 
B)  Client with a Glasgow Coma Scale score that was 9 and is now is 12 
C)  Client with a moderate brain injury who is amnesic for the event 
D)  Client who is requesting pain medication for a headache

Exam 45: Care of Critically Ill Patients with Neurologic Problems