From the disk

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 4th Edition

Self-Assessment Questions

Chapter 45: Interventions for Critically Ill Clients with Neurologic Problems


1.     What are the major pathophysiologic processes causing neurologic deficits with hemorrhagic stroke?

A.     Meningeal scar tissue formation and atrophy
B.     Cerebrovascular inflammation and fibrosis
C.     Ischemia and cell death of glial cells
D.     Interruption of blood vessel integrity

Correct Answer: D


2.     Which of the following health problems related by the client alerts the nurse to the risk for an embolic stroke?

A.     Insulin independent diabetes mellitus
B.     Mitral valve replaced one year ago
C.     Use of oral contraceptives
D.     Degenerative joint disease

Correct Answer: B


3.     The client has experienced a lacunar infarct of the thalamus. Which of the following deficits should the nurse expect this client to manifest?

A.     Bilateral motor weakness
B.     Loss of sensory perception
C.     Poorly coordinated eye movement
D.     Difficulty with receptive and expressive speech

Correct Answer: B


4.     Which nursing diagnosis would be appropriate for a client who has amaurosis fugax as the result of a stroke?

A.     Disturbed sensory perception
B.     Total urinary incontinence
C.     Impaired physical mobility
D.     Unilateral neglect

Correct Answer: A


5.     A client with a hemorrhagic stroke becomes increasingly restless and complains of a headache. Which action should you take?

A.     Lower the head of the bed to a flat position.
B.     Notify the health care provider.
C.     Medicate the client for pain.
D.     Increase the IV fluid rate.

Correct Answer: B


6.     The sibling of a client with a hemorrhagic stroke asks you when the client will be treated with tPA, just like the sibling was after a stoke one year ago. What is your best response?

A.     “tPA may be of some benefit in strokes caused by blood clots, but it can make strokes caused by hemorrhage worse.”
B.     “tPA is most beneficial as therapy for strokes when given at least 72 hours after the onset of stroke symptoms.”
C.     “The use of tPA as treatment for stroke is controversial.”
D.     “This risk for an allergic reaction is too great.”

Correct Answer: A


7.     The nurse is admitting a client with a possible brain attack. Which of the following data first alerts the nurse to the probability of a thrombotic event causing the brain attack? The:

A.     client was treated for bacterial meningitis with seizures two years ago.
B.     client has experienced three episodes of right-sided weakness in one week.
C.     client’s onset of symptoms of neurologic problems is in the daytime.
D.     client has adult onset diabetes mellitus.

Correct Answer: B


8.     The family of a client who has suffered a stroke asks you why the client is being discharged to a rehabilitation facility rather than directly home. What is your best response? To:
A.     insure that your family member will be able to function independently when discharged home
B.     relieve you and your family of caregiving responsibilities as long as possible
C.     provide ongoing therapy and care in order to maximize function
D.     treat the depression that most people with a stroke experience

Correct Answer: C


9.     Which statement made by the client with a stroke indicates a need for further discharge teaching? “I will

A.     call for assistance to climb the stairs.”
B.     have my family install handrails in the bathtub.”
C.     continue my physical therapy after my discharge.”
D.     take my antihypertensives only if my blood pressure is elevated.”

Correct Answer: D


10.     Which of the following clinical manifestations in a client following head trauma alerts the nurse to the possibility of a basilar skull fracture? The:

A.     client is lethargic and disoriented.
B.     client has clear fluid draining from the ear.
C.     scalp is lacerated at the site of injury.
D.     skull is depressed at the site of injury.

Correct Answer: B


11.     Which statement regarding the pathophysiology of closed head injury is true?

A.     The impacted area of the bone bends inward.
B.     Damage occurs to the gray matter of the cerebral cortex.
C.     The scalp is lacerated creating an opening to the brain tissue.
D.     The primary cause of closed head injuries is the penetration of an object.

Correct Answer: B


12.     A client with a major head injury is about to be discharged home. The client’s family expresses concern over the possible psychosocial or behavioral manifestations associated with traumatic brain injury. What is your best response?

A.     “Your family member may not recognize you, as long-term memory may be most affected.”
B.     “Your family member may become more outgoing, as depression is rare.”
C.     “Personality changes, such as temper outbursts, can be expected.”
D.     “Most people have few difficulties with learning and concentration.”

Correct Answer: C


13.     When taking the hourly vital signs of a client with a severe head injury, you note the client’s urine output has decreased from 50 mL/hour to 4 mL/hour. What is your best first action?

A.     Check to see if a diuretic is ordered.
B.     Increase the IV flow rate.
C.     Notify the physician.
D.     Document the finding.

Correct Answer: C


14.     You are caring for a client who has undergone a craniotomy for treatment of a primary brain tumor. Over the past three hours, the client’s urine output decreases dramatically to <20 mL/hr and serum sodium levels are decreased. What complication of the surgery is suspected?

A.     SIADH
B.     Hydrocephalus
C.     Subdural hematoma
D.     Neurogenic pulmonary edema

Correct Answer: A


15.     A client who has undergone a craniotomy for a primary brain tumor has just returned to the unit. In which position should this client be placed for maximum comfort and safety?

A.     High Fowler’s position
B.     Trendelenburg position
C.     Supine, with the head of the bed elevated to 30°
D.     Prone, with the head of the bed elevated to 45°

Correct Answer: C