Chapter 35--Dysfunction of the Brain: Nursing Management

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Chapter 35--Dysfunction 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 dri... nks with caffeine. 2. monitor blood pressure. 3. increase amounts of sodium in the diet. 4. monitor weight and activity. PTS: 1 DIF: 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. 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). PTS: 1 DIF: Analyze REF: Diagnostic 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. PTS: 1 DIF: Apply REF: Pharmacology 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 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. 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 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. PTS: 1 DIF: 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. 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 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 client’s treatment could include all of the following EXCEPT: 1. photo DNA therapy. 2. radiation. 3. chemotherapy. 4. surgery. 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 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 client’s treatment? 1. Carmustine 2. Digoxin 3. Aminophylline 4. Acetaminophen 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 PTS: 1 DIF: 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 client’s 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 client’s 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. 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. PTS: 1 DIF: 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. PTS: 1 DIF: 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 PTS: 1 DIF: 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. PTS: 1 DIF: Apply REF: Brain Tumors: Planning and Implementation [Show More]

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