Unit 5 Chapter 16 Path Flashcards
The health care provider is concerned that a client may be at risk for problems with cerebral blood flow. The most important data to assess would be:
A) Decreased level of PCO2
B) Decreased level of carbon dioxide
C) Decreased hydrogen ions
D) Decreased level of oxygen
D) Decreased level of oxygen
Rationale:Regulation of blood flow to the brain is controlled largely by autoregulatory or local mechanisms that respond to the metabolic needs of the brain. Metabolic factors affecting cerebral blood flow include an increase in carbon dioxide and hydrogen ion concentrations; cerebral blood flow is affected by decreased O2 levels and increased hydrogen ions, carbon dioxide, and PCO2 levels.
According to the Glasgow Coma Scale, opening one’s eyes to only painful stimuli would receive which score?
A) 3
B) 2
C) 4
D) 1
B) 2
Rationale:Only opening eyes to painful stimulation is scored as a 2. Spontaneously opening eyes is scored as a 4; opening eyes to speech is scored as a 3; no opening is scored as a 1.
A client is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to:
A) administer analgesics for the relief of pain.
B) administer IV tissue plasminogen activator (tPA).
C) prepare the client for emergency surgery.
D) monitor vital signs closely for improvement.
B) administer IV tissue plasminogen activator (tPA).
Rationale:tPA administration is the treatment of choice for an ischemic stroke after confirmation that it is not a hemorrhagic stroke. Monitor vital signs and provide pain relief to prevent complications.
A client’s recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which treatment measure is most likely to resolve this health problem?
A) Administration of hypertonic intravenous solution
B) Aggressive diuresis
C) Placement of a shunt
D) Lumbar puncture
C) Placement of a shunt
Rationale:Hydrocephalus represents a progressive enlargement of the ventricular system due to an abnormal increase in cerebrospinal fluid (CSF) volume. This increase in CSF volume can be resolved by the placement of a shunt to drain the offending fluid volume. Diuresis, hypertonic solution administration, and lumbar puncture are not usual treatment modalities.
The family of a male client documented to be in a vegetative state excitedly reports to the nurse that the client has just opened his eyes for the first time. The best response by the nurse is:
A) “That is a miracle.”
B) “That is a just a reflexive action.”
C) “Clients in a vegetative state often open and close their eyes.”
D) “I will come and assess the client.”
D) “I will come and assess the client.”
Rationale:The nurse should assess the client for concurrent awareness as this is the first time that the spontaneous eye opening has occurred. The nurse should be aware that clients in a persistent vegetative state often have spontaneous eye opening without concurrent awareness. This is often confusing for hopeful families.
The emergency department nurse is caring for a client who fell and has a head injury. Which assessment would be noted during the early stage of increased intracranial pressure?
A) Vomiting
B) Stable vital signs
C) Hemiplegia
D) Nonreactive pupils
B) Stable vital signs
Rationale:The vital signs remain unchanged in the early stage of increased intracranial pressure. The remaining options are characteristic of late signs.
Which symptoms would support the diagnosis of a stroke involving the posterior cerebral artery? Select all that apply.
A) Denial of paralyzed side
B) Contralateral hemiplegia
C) Loss of central vision
D) Aphasia
E) Repeating of verbal responses
C) Loss of central vision
E) Repeating of verbal responses
Rationale:Posterior cerebral artery stroke would produce visual defects and the repeat of verbal and motor responses. The other options are seen in middle cerebral artery strokes.
The nurse would consider which factors when providing education regarding modifiable risk factors for stroke? Select all that apply.
A) The early syptoms of an impending stroke
B) Controlling blood pressure
C) Monitoring diabetes mellitus
D) Selecting low fat foods
E) Avoiding excessive alcohol use
B) Controlling blood pressure
C) Monitoring diabetes mellitus
D) Selecting low fat foods
E) Avoiding excessive alcohol use
Rationale:Hypertension, hypercholesteremia, diabetes, and heavy alcohol use are all modifiable risk factors for stroke. Identifying the signs of impending stroke assures early intervention but does not affect the risk of developing the condition
Which medication would be recommended for myoclonic seizures?
A) Lamotrigine
B) Valproic acid
C) Carbamazepine
D) Gabapentin
B) Valproic acid
Rationale:Valproic acid has proven to be effective with myoclonic seizures. The other medications are used primarily with partial seizures or tonic-clonic seizures.
The CT scan report identified that a client with a skull fracture has developed a hematoma that resulted from a torn artery. The report would be interpreted as:
A) Chronic subdural hematoma
B) Subdural hematoma
C) Epidural hematoma
D_) Intracranial hematoma
C) Epidural hematoma
Rationale:An epidural hematoma is one that develops between the inner side of the skull and the dura, usually resulting from a tear in an artery, most often the middle meningeal, usually in association with a head injury in which the skull is fractured. A subdural hematoma results from a torn vein; chronic subdural hematoma is common in older persons. Brain atrophy causes the brain to shrink away from the dura and to stretch fragile bridging veins. An intracranial hematoma occurs when a blood vessel ruptures within the brain or between the skull and the brain.
A client who is diagnosed with seizures describes feeling a strange sensation before losing consciousness. The family members report that the client has been smacking his lips prior to having a seizure. Which type of seizure disorder presents with these symptoms?
A) Generalized seizures
B) Atonic seizure
C) Simple partial seizure or prodrome
D) Complex partial or focal seizure with impairment of consciousness
D) Complex partial or focal seizure with impairment of consciousness
Rationale:Complex partial seizures, or focal seizures with impairment of consciousness, are often accompanied by automatisms, which are repetitive, nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. They are sometime called psychomotor seizures. Simple partial seizures, or prodromes, would not have a loss of consciousness. Atonic seizures, a category of generalized seizures, indicate involvement of both brain hemispheres at the onset.
Generalized convulsive status epilepticus is a medical emergency caused by a tonic–clonic seizure that does not spontaneously end, or recurs in succession without recovery. What is the first-line drug of choice to treat status epilepticus?
A) Intramuscular cyproheptadine
B) Intravenous cyclobenzaprine
C) Intramuscular diazepam
D) Intravenous lorazepam
D) Intravenous lorazepam
Rationale:Treatment consists of appropriate life support measures. Medications are given to control seizure activity. Intravenously administered diazepam or lorazepam is considered first-line therapy for the condition. Lorazepam is not given intramuscularly in status epilepticus. Cyclobenzaprine and cyproheptadine are not used to treat status epilepticus
The nurse is explaining to a client’s family how vasogenic brain edema occurs. The most appropriate information for the nurse to provide would be:
A) There is a decrease in the amount of fluid volume in the brain.
B) There is an increase in the production of cerebrospinal fluid volume.
C) Normal physiologic circumstances result in decreased adsorption of CSF.
D) The blood–brain barrier is disrupted, allowing fluid to escape into the extracellular fluid.
D) The blood–brain barrier is disrupted, allowing fluid to escape into the extracellular fluid.
Rationale:Vasogenic brain edema occurs with conditions that impair the function of the blood–brain barrier and allow the transfer of water and protein from the vascular space into the interstitial space. Increased production of CSF and decreased absorption result in hydrocephalus. It occurs in conditions such as hemorrhage, brain injury, and infectious processes
A client has started having uncontrolled seizures that are not responding to usual medications. Nurses working with the client must pay special attention to which priority aspects of this client’s care? Assessment of:
A) Respiratory status and oxygen saturation
B) Ability to grasp hands and squeeze on command
C) ECG for arrhythmias
D) Urine output and continence
A) Respiratory status and oxygen saturation
Rationale:Tonic–clonic status epilepticus is a medical emergency and, if not promptly treated, may lead to respiratory failure and death. Treatment consists of appropriate life support measures. Airway/breathing is always the priority in this emergency situation.
A child has developed a benign brain tumor in the cerebellum and the floor of the third ventricle. The proper documentation for this type of tumor includes which terminology?
A) Fibrillary astrocytomas
B) Pilocytic astrocytomas
C) Oligodendrogliomas
D) Ependymomas
B) Pilocytic astrocytomas
Rationale:Pilocytic astrocytomas are commonly found in children and young adults, typically located in the cerebellum or in the floor and walls of the third ventricle, in the optic chiasm and nerves, and occasionally in the cerebral hemispheres. These tumors are benign and grow slowly. The other tumors do not occur in the walls of the cerebellum.
