NCLEX Neuro assess, TIA, stroke, ICP

NCLEX Neuro assess, TIA, stroke, ICP Leave the first rating Students also studied Terms in this set (52) Science MedicineNeurology Save NCLEX Questions Parkinson Disease...20 terms SMathews926Preview Head Injuries and Stroke - NCLEX Q...54 terms noot-colePreview NCLEX questions on Shock 25 terms LauraRNtobePreview stroke 27 terms gra Which statement is true for a patient who has pathology in Wernicke's area of the cerebrum?

• Receptive speech is affected.
• The parietal lobe is involved.
• Sight processing is abnormal.
• An abnormal Romberg test is present.

A The temporal, not parietal, lobe contains the Wernicke area, which is responsible for receptive speech and integration of somatic, visual, and auditory data. Sight processing occurs in the occipital lobe. The Romberg test is used to assess the position sense of the lower extremities.After a major head trauma, the patient's respiratory and cardiac functions are affected. Which area of the brain is damaged?

• Temporal lobe of the cerebrum
• Brainstem
• Cerebellum
• Spinal nerves

B The brainstem includes the midbrain, pons, and medulla. The vital centers concerned with respiratory, vasomotor, and cardiac function are located in the medulla. Integration of somatic, visual, and auditory data occurs in the temporal lobe. The cerebellum coordinates voluntary movement, trunk stability, and equilibrium. Motor and spinal nerves serve particular areas of the body.What is the purpose of the blood-brain barrier?

• To protect the brain by cushioning
• To inhibit damage from external trauma
• To keep harmful agents away from brain tissue
• To provide the blood supply to brain tissue

C The blood-brain barrier is a physiologic barrier between capillaries and brain tissue. The structure of the brain's capillaries is different from others, and substances that are harmful are not allowed to enter brain tissue. Lipid-soluble compounds enter the brain easily, but water-soluble and ionized drugs enter slowly. The spinal fluid and meninges help cushion the brain. The skull protects from external trauma. Blood is supplied to the brain from the internal carotid arteries and the vertebral arteries.An obstruction of the anterior cerebral arteries affects

• visual imaging.
• balance and coordination.
• judgment, insight, and reasoning.
• visual and auditory integration for language

comprehension.C The anterior cerebral artery feeds the medial and anterior portions of the frontal lobes. The anterior portion of the frontal lobe controls higher-order processes such as judgment and reasoning.

Paralysis of lateral gaze indicates a lesion of cranial nerve

A. II.

B. III.

C. IV.

D. VI.

D Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle is innervated by cranial nerve VI and is the primary muscle that is responsible for lateral eye movement What is important when obtaining a history of a patient with a neurologic problem?

• Have patient agree or disagree with suggested

symptoms to obtain a thorough history.

• Mode of onset and course of illness are essential

aspects.

• Check out neurologic problems caused by nutrition by

asking about sodium.

• Assess for dementia using the Confusion Assessment

Method (CAM).B The mode of onset and the course of the illness are especially important aspects of the history. The nature of a neurologic disease process often can be described by these facts alone. Avoid suggesting certain symptoms or using leading questions. Nutritional deficits of B vitamins are most likely to cause neurologic problems. CAM is used to assess for delirium.What is the most common visual field change resulting from a brain lesion?

• Diplopia
• Blurred vision
• Presbyopia
• Hemianopsia

D Visual field changes resulting from brain lesions are usually diagnosed as hemianopsia (one half of the visual field) or quadrantanopsia (one fourth of the visual field) or monocular vision.When assessing a patient with a traumatic brain injury, you notice uncoordinated movement of the extremities. How would you document this?

• Ataxia
• Apraxia
• Anisocoria
• Anosognosia

A Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellar disorders, or certain medications.How do you assess the accessory nerve?

• Assess the gag reflex by stroking the posterior

pharynx.

• Ask the patient to shrug the shoulders against

resistance.

• Ask the patient to push the tongue to either side

against resistance.

• Have the patient say "ah" while visualizing elevation of

the soft palate B The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance. The other options are used to test the glossopharyngeal and vagus nerves.When assessing motor function of a patient admitted with a stroke, you notice mild weakness of the arm demonstrated by downward drifting of the extremity.How would you accurately document this finding?

• Athetosis
• Hypotonia
• Hemiparesis
• Pronator drift

D Downward drifting of the arm or pronation of the palm is identified as pronator drift. Hemiparesis is weakness of one side of the body, hypotonia describes flaccid muscle tone, and athetosis is a slow, writhing, involuntary movement of the extremities

A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which assessment should you complete before this diagnostic study?

• Assess the patient's immunization history.
• Screen the patient for any metal parts or a pacemaker.
• Assess the patient for allergies to shellfish, iodine, or

dyes.

• Assess the patient's need for tranquilizers or

antiseizure medications.C Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media for CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in most patients.How should you most accurately assess the position sense of a patient with a recent traumatic brain injury?

• Ask the patient to close his or her eyes and slowly

bring the tips of the index fingers together.

• Ask the patient to maintain balance while standing with

his or her feet together and eyes closed.

• Ask the patient to close his or her eyes and identify the

presence of a common object on the forearm.

• Place the two points of a calibrated compass on the

tips of the fingers and toes, and ask the patient to discriminate the points.B The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other tests of neurologic function do not directly assess position sense.Why are the data regarding mobility, strength, coordination, and activity tolerance important for you to obtain?

• Many neurologic diseases affect one or more of these

areas.

• Patients are less able to identify other neurologic

impairments.

• These are the first functions to be affected by

neurologic disease.

• Aspects of movement are the most important function

of the nervous system.A Many neurologic disorders can cause problems in the patient's mobility, strength, and coordination. These problems can result in changes in the patient's usual activity and exercise patterns.Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)?

• Heart rate increases from 90 to 110 beats/minute
• Kussmaul respirations
• Temperature over 100.4° F (38° C)
• Heart rate decreases from 75 to 55 beats/minute

D Cushing's triad is systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and slowed respirations. The rise in blood pressure is an attempt to maintain cerebral perfusion, and it is a neurologic emergency because decompensation is imminent. The other options are not part of Cushing's triad.The patient had an acute ischemic stroke 4 hours ago and has an elevated blood pressure. What action should you take?

• Document the findings because the increased

pressure is needed to perfuse the brain.

• Administer an antihypertensive medication to prevent

additional damage.

• Hyperventilate the patient to cause vasodilatation.
• Teach patient about a low sodium diet.

A After a stroke, temporary hypertension is needed to perfuse the area of swelling.No treatment is done unless the pressure is above 220/110 mm Hg in the first few hours. Aggressive lowering of blood pressure is not done, because if the pressure drops, it can prevent regional perfusion and lead to local tissue damage.Hyperventilation is done if hypercapnia is identified, but it is not prophylactic.

Which response can be expected in a patient with low oxygen concentration and acidosis?

• Decreased cerebral fluid flow with decreased cerebral

pressure

• Vasodilation with increased cerebral pressure
• Systemic hypotension with decreased cerebral

pressure

• Cerebral tissue hypertrophy with increased cerebral

pressure B Low concentration of oxygen ions and high concentration of hydrogen ions cause vasodilation, which can result in increased ICP if autoregulation has failed. The other options are not possible A patient being monitored has an ICP pressure of 12 mm Hg. You understand that this pressure reflects

• a severe decrease in cerebral perfusion pressure.
• an alteration in the production of cerebrospinal fluid.
• the loss of autoregulatory control of intracranial

pressure.

• a normal balance between brain tissue, blood, and

cerebrospinal fluid.D Normal ICP ranges from 10 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.Which option is the most sensitive indication of increased ICP?

• Papilledema
• Cushing's triad
• Projectile vomiting
• Change in the level of consciousness (LOC)

D The LOC is the most sensitive and reliable indicator of the patient's neurologic status. Changes in LOC are a result of impaired cerebral brain flow. Papilledema and Cushing's triad are late signs. Projectile vomiting is not a sensitive indicator.What sign would make you suspect the cause of increased ICP involves the hypothalamus?

• Contralateral hemiparesis
• Ipsilateral pupil dilation
• Rise in temperature
• Decreased urine output

C If the ICP affects the hypothalamus, there can be a change in the body temperature. Increasing ICP can cause changes in motor ability, with contralateral hemiparesis. Compression of the cranial nerve III causes dilation of the pupil on the side of the mass (ipsilateral). Decreased urine output is not specific for hypothalamic function.A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects?

• Urine output increases from 30 mL to 50 mL/hour.
• Blood pressure remains less than 150/90 mm Hg.
• The LOC improves.
• No crackles are auscultated in the lung fields.

C LOC is the most sensitive indicator of ICP. Mannitol is an osmotic diuretic that works to decrease the ICP by plasma expansion and an osmotic effect. Although the other options may indicate a therapeutic effect of a diuretic, they are not the main reason this drug is given.A patient with increased ICP is being monitored in the intensive care unit (ICU) with a fiberoptic catheter. Which order is a priority for you?

• Perform hourly neurologic checks.
• Take a complete set of vital signs.
• Administer the prescribed mannitol (Osmitrol).
• Give an H2-receptor blocker.

c he priority is to treat the known existing problem, and mannitol is the only thing that can do that. Because the patient is having the current pressure measured with objective numbers, treating the known problem is a priority over additional assessments. H2-blockers are given when corticosteroids are administered to help prevent gastrointestinal bleeding, but they are not a priority compared with the treatment of ICP.