NCLEX Neuro assess, TIA, stroke, ICP
Terms in this set (30)
Paralysis of lateral gaze indicates a lesion of cranial nerve
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?
A. Have patient agree or disagree with suggested symptoms to obtain a thorough history.
B. Mode of onset and course of illness are essential aspects.
C. Check out neurologic problems caused by nutrition by asking about sodium.
D. Assess for dementia using the Confusion Assessment Method (CAM).
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?
B. Blurred vision
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 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?
A. Assess the gag reflex by stroking the posterior pharynx.
B. Ask the patient to shrug the shoulders against resistance.
C. Ask the patient to push the tongue to either side against resistance.
D. Have the patient say "ah" while visualizing elevation of the soft palate
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?
D. Pronator drift
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?
A. Assess the patient's immunization history.
B. Screen the patient for any metal parts or a pacemaker.
C. Assess the patient for allergies to shellfish, iodine, or dyes.
D. Assess the patient's need for tranquilizers or antiseizure medications.
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?
A. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together.
B. Ask the patient to maintain balance while standing with his or her feet together and eyes closed.
C. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm.
D. Place the two points of a calibrated compass on the tips of the fingers and toes, and ask the patient to discriminate the points.
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?
A. Many neurologic diseases affect one or more of these areas.
B. Patients are less able to identify other neurologic impairments.
C. These are the first functions to be affected by neurologic disease.
D. Aspects of movement are the most important function of the nervous system.
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)?
A. Heart rate increases from 90 to 110 beats/minute
B. Kussmaul respirations
C. Temperature over 100.4° F (38° C)
D. Heart rate decreases from 75 to 55 beats/minute
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?
A. Document the findings because the increased pressure is needed to perfuse the brain.
B. Administer an antihypertensive medication to prevent additional damage.
C. Hyperventilate the patient to cause vasodilatation.
D. Teach patient about a low sodium diet.
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 option is the most sensitive indication of increased ICP?
B. Cushing's triad
C. Projectile vomiting
D. Change in the level of consciousness (LOC)
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.
A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects?
A. Urine output increases from 30 mL to 50 mL/hour.
B. Blood pressure remains less than 150/90 mm Hg.
C. The LOC improves.
D. No crackles are auscultated in the lung fields.
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.
You plan care for the patient with increased ICP with the knowledge that the best way to position the patient is to
A. keep the head of the bed flat.
B. elevate the head of the bed to 30 degrees.
C. maintain patient on the left side with the head supported on a pillow.
D. use a continuous-rotation bed to continuously change patient position.
You should maintain the patient with increased ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. You should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system in the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. Careful evaluation of the effects of elevation of the head of the bed on the ICP and the CPP is required.
An elderly patient fell at home. Which information from the patient's history makes this patient at high risk for an intracerebral bleed?
A. History of a heart condition
B. Taking warfarin (Coumadin)
C. Has lost consciousness for 5 seconds
D. History of migraine headaches
Anticoagulant use is associated with increased hemorrhage and more severe head injury. A heart condition may have caused the syncope that caused the fall, but it was not solely responsible for increased bleeding. Concussions are usually minor injuries that resolve, and the typical signs include a brief disruption in level of consciousness (LOC). If the loss of consciousness is less than 5 minutes, patients are usually discharged. Headache by itself does not indicate a risk for intracerebral bleeding.
You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)?
A. Eye opening
B. Abstract reasoning
C. Best verbal response
D. Best motor response
E. Cranial nerve function
The three dimensions of the Glasgow Coma Scale are eye opening, best verbal response, and best motor response.
The patient is diagnosed with a brain tumor. Which option is the correct understanding of the preferred treatment?
A. Surgical removal is preferred, even if the tumor is not malignant.
B. Chemotherapy is a common and effective treatment.
C. Stereotactic radiosurgery is the preferred treatment.
D. A large dose of intravenous steroid therapy is preferred.
Surgical removal is the preferred treatment. It can reduce tumor mass (decreasing intracranial pressure [ICP]), provides relief of symptoms, and extend survival time. Even a benign mass has a malignant effect by taking up space. Traditional chemotherapy effectiveness is limited because of the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Stereotactic radiosurgery delivers a high, concentrated dose of radiation precisely directed and is used when conventional surgery has failed or is not an option. Corticosteroids are not an integral part of therapy, but are used to control complications of radiation therapy.
What is most important finding for you to act on for a patient who had a craniotomy?
A. Sodium: 134 mEq/L
B. While blood cell (WBC) count: 11,000/μL
C. Urine specific gravity: 1.001
D. Blood urea nitrogen (BUN): 25 mg/dL
Patients need frequent monitoring for sodium regulation, onset of diabetes insipidus, and severe hypovolemia. Normal specific gravity for urine should not be below 1.003 and this low value is a priority.
A female patient has left-sided hemiplegia after an ischemic stroke that occurred 2 weeks earlier. How should you best promote the integrity of the patient's skin?
A. Position the patient on her weak side most of the time.
B. Alternate the patient between supine and side-lying positions.
C. Avoid the use of pillows to promote independence in positioning.
D. Establish a schedule for the massage of areas where skin breakdown emerges.
A position change schedule should be established for stroke patients. An example is side-backside positioning, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.
Which sensory-perceptual deficit is associated with a left-brain stroke?
A. Overestimation of physical abilities
B. Difficulty judging position and distance
C. Slow and possibly fearful performance of tasks
D. Impulsivity and impatience at performing tasks
Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-brain stroke.
Which of the following patients is at highest risk for a stroke?
A. An obese, 45-year-old Native American
B. A 35-year-old Asian American woman who smokes
C. A 32-year-old, white woman taking oral contraceptives
D. A 65-year-old African American man with hypertension
Nonmodifiable risk factors for stroke include age (>65 years), male gender, ethnicity or race (African Americans > Hispanics, Native Americans/Alaska Natives, and Asian Americans > whites), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocysteinemia, and sickle cell disease.
Which factor related to cerebral blood flow most often determines the extent of cerebral damage from a stroke?
A. Amount of cardiac output
B. Oxygen content of the blood
C. Degree of collateral circulation
D. Level of carbon dioxide in the blood
The extent of the stroke depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.
What information provided by the patient can help differentiate a hemorrhagic stroke from a thrombotic stroke?
A. Sensory disturbance
B. A history of hypertension
C. Presence of motor weakness
D. Sudden onset of severe headache
A hemorrhagic stroke usually causes sudden onset of symptoms, including neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.
A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the
B. vertebral artery.
C. left middle cerebral artery.
D. right middle cerebral artery.
If the middle cerebral artery is involved in a stroke, the expected clinical manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side.
You explain to the patient with a stroke who is scheduled for angiography that the test is used to determine the
A. presence of increased intracranial pressure (ICP).
B. site and size of the infarction.
C. patency of the cerebral blood vessels.
D. presence of blood in the cerebrospinal fluid.
Angiography provides visualization of cerebral blood vessels, can provide an estimate of perfusion, and can detect filling defects in the cerebral arteries.
A patient experiencing TIAs is scheduled for a carotid endarterectomy. You explain that this procedure is done to
A. decrease cerebral edema.
B. reduce the brain damage that occurs during a stroke in evolution.
C. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.
D. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.
In carotid endarterectomy, the atheromatous lesions are removed from the carotid artery to improve blood flow.
For a patient with a suspected stroke, which important piece of information should you obtain?
A. Time of the patient's last meal
B. Time at which stroke symptoms first appeared
C. Patient's hypertension history and management
D. Family history of stroke and other cardiovascular diseases
During initial evaluation, the single most important point in the patient's history is the time of onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with an acute onset of symptoms.
Bladder training for a male patient who has urinary incontinence after a stroke includes
A. limiting fluid intake.
B. keeping a urinal in place at all times.
C. assisting the patient to stand to void.
D. catheterizing the patient every 4 hours.
In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most given between 8:00 AM and 7:00 PM; (2) scheduled toileting every 2 hours using a bedpan, commode, or bathroom; and (3) observing signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) focusing the patient on the need to urinate with a direct command; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 AM and 7:00 PM; and (6) encouraging the usual position for urinating (standing for men and sitting for women).
What are the common psychosocial reactions of the patient to the stroke (select all that apply)?
D. Sleep disturbances
E. Denial of the severity of the stroke
The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression and symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially, as well as changing roles and responsibilities. Reactions vary considerably but may involve fear, apprehension, denial of the severity of the stroke, depression, anger, and sorrow.
What is the treatment of choice for normal pressure hydrocephalus?
A. Donepezil (Aricept)
C. Furosemide (Lasix)
Normal pressure hydrocephalus results from an obstruction in the flow of cerebrospinal fluid (CSF), which causes a buildup of CSF fluid in the brain. Manifestations of the condition include dementia, urinary incontinence, and difficulty walking. Meningitis, encephalitis, or head injury may cause the condition. If diagnosed early, it is treated by surgically inserting a shunt to divert the fluid.