NCLEX Stroke, ICP, Traumatic brain injury NCLEX questions

NCLEX Stroke, ICP, Traumatic brain injury NCLEX questions Leave the first rating Students also studied Terms in this set (36) Mount Saint Joseph UniversityNUR 508 Save Spinal Cord Injury NCLEX 26 terms ET0003Preview Diabetes Mellitus Complications (H...24 terms student_257Preview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview ATI com 198 term h_tr A patient is admitted with uncontrolled atrial fibrillation.The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?*

• Ischemic thrombosis
• Ischemic embolism
• Hemorrhagic
• Ischemic stenosis

The answer is B.If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.Which patient below is at most risk for a hemorrhagic stroke?*

• A 65 year old male patient with carotid stenosis.
• A 89 year old female with atherosclerosis.
• A 88 year old male with uncontrolled hypertension

and a history of brain aneurysm repair 2 years ago.

• A 55 year old female with atrial flutter.

The answer is C.A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) All the other options are at risk for an ischemic type of stroke.You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect

about this condition:*

• TIAs are caused by a temporary decrease in blood

flow to the brain.

• TIAs produce signs and symptoms that can last for

several weeks to months.

• A TIAs is a warning sign that an impending stroke may

occur.

• TIAs don't require medical treatment.

The answers are B and D.Options A and C are CORRECT statements about TIAs. However, option B is wrong because TIAs produce signs and symptoms that can last a few minutes to hours and resolve (NOT several weeks to months). Option D is wrong be TIAs do require medical treatment.

A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding?*

• Vision problems
• Balance impairment
• Language difficulty
• Impaired short-term memory

The answer is B.The cerebellum is important for coordination and balance.A patient is demonstrating signs and symptoms of stroke.The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding?*

• Brain stem
• Hippocampus
• Parietal lobe
• Occipital lobe

The answer is D.The occipital lobe is responsible for vision and color perception.During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke.Which risk factors below for stroke are modifiable?*

• Smoking
• Family history
• Advanced age
• Obesity
• Sedentary lifestyle

The answers are A, D, and E.These risk factors are modifiable in that the patient can attempt to change them to prevent another stroke in the future. The other risk factors are NOT modifiable.You're patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected?*

• Expressive; Wernicke's area
• Receptive, Broca's area
• Expressive; hippocampus
• Receptive; Wernicke's area

The answer is D.In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered?*

• 6 hours after the onset of stroke symptoms
• 4.5 hours before the onset of stroke symptoms
• 3 hours after the onset of stroke symptoms
• 12 hours before the onset of stroke symptoms

The answer is C.tPA dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke?*

• A patient with a CT scan that is negative.
• A patient whose blood pressure is 200/110.
• A patient who is showing signs and symptoms of

ischemic stroke.

• A patient who received Heparin 24 hours ago.

The answers are B and D.Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc.are NOT a candidate for tPA. tPA is only for an ischemic stroke.

Normal ICP ranges from:5 to 10 mm Hg

The earliest signs of increased ICP the nurse should assess for include

• Cushing's triad
• unexpected vomiting
• decreasing level of consciousness (LOC)
• dilated pupil with sluggish response to light
• One of the most sensitive signs of increased intracranial pressure (ICP) is a

decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur The nurse recognizes the presence of Cushing's triad in the patient with

• Increased pulse, irregular respiration, increased BP
• decreased pulse, irregular respiration, increased pulse

pressure

• increased pulse, decreased respiration, increased

pulse pressure

• decreased pulse, increased respiration, decreased

systolic BP

• Cushing's triad consists of three vital sign measures that reflect ICP and its

effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is

• aseptic technique to prevent infection
• constant monitoring of ICP waveforms
• removal of CSF to maintain normal ICP
• sampling CSF to determine abnormalities
• Aseptic technique to prevent infection- An intraventricular catheter is a fluid

coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as

• 6
• 7
• 9
• 11
• 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4

Total = 7 When assessing the body function of a patient with increased ICP, the nurse should initially assess

• corneal reflex testing
• extremity strength testing
• pupillary reaction to light
• circulatory and respiratory status
• Circulatory and respiratory status- Of the body functions that should be

assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation) A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is

• avoiding positioning the patient with neck and hip

flexion

• maintaining hyperventilation to a PaCO2 of 15 to 20

mm Hg

• clustering nursing activities to provide periods of

uninterrupted rest

• routine suctioning to prevent accumulation of

respiratory secretions

• Avoiding positioning the patient with neck and hip flexion- Nursing care

activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

An unconscious patient with increased ICP in on ventilatory support. The nurse notifies the health care provider when arterial blood gas measurement results reveal a

• pH of 7.43
• SaO2 of 94%
• PaO2 of 50 mm Hg
• PaCO2 of 30 mm Hg
• PaO2 of 50 mm Hg- A PaO2 of 50 mm Hg reflects a hypoxemia that may lead

to further decreased cerebral perfusion and hypoxia and must be corrected. The pH of SaO2 are within normal range, and a PaCO2 of 30 mm Hg reflects acceptable value for the patient with increased ICP When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is

• maintaining cervical spine precautions
• determining the presence of increased ICP
• monitoring for changes in neurologic status
• establishing IV access with a large-bore catheter
• In addition to monitoring for a patent airway during emergency care of the

patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge or the patient, the nurse explains to the patient and the family that

• continuous improvement in the patient's condition

should occur until he has returned to pre trauma status

• the patient's complete recovery may take years, and

the family should plan for his long term dependent care

• the patient is likely to have long term emotional and

mental changes that may require continued professional help

• role changes in family members will be necessary

because the patient will be dependent on his family for care and support

• Residual mental and emotional changes of brain trauma with personality

changes are often the most incapacitating problems following head injury and are common in patients who have been comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning, and professional assistance may be required.There is no indication he will be dependent on others for care, but he likely will not return to pre trauma status Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the

• ability to return home in 6 days
• ability to meet all self-care needs
• acceptance of residual neurologic deficits
• absence of signs and symptoms of increased ICP
• Absence of signs and symptoms of increased ICP- The primary goal after

cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to

• keep the head of the bed flat
• elevate the head of the bed to 30 degrees
• maintain patient on the left side with the head

supported on a pillow

• use a continuous rotation bed to continuously change

patient position

• elevate the head of the bed to 30 degrees