Neuro CVA(Stroke)1. Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A. Placing the client on the back with a small pillow under the head.B. Keeping portable suctioning equipment at the bedside.C. Opening the clients mouth with a padded tongue blade.D. Cleaning the clients mouth and teeth with a toothbrush.2. A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).B. Discuss the precipitating factors that caused the symptoms.C. Schedule for A STAT computer tomography (CT) scan of the head.D. Notify the speech pathologist for an emergency consult.3. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Current medications.B. Complete physical and history.C. Time of onset of current stroke.D. Upcoming surgical procedures.4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the clients: A. PulseB. RespirationsC. Blood pressureD. Temperature5. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol levelB. Pupil size and papillary responseC. Vowel soundsD. Echocardiogram6. What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability.B. Vasoconstriction.C. Dissolved emboli.D. Prevention of hemorrhage7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. An oral anticoagulant medication.B. A beta-blocker medication.C. An anti-hyperuricemic medication.D. A thrombolytic medication.8. Which client would the nurse identify as being most at risk for experiencing a CVA? A. A 55-year-old African American male.B. An 84-year-old Japanese female.C. A 67-year-old Caucasian male.D. A 39-year-old pregnant female.9. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl.B. A right-sided carotid bruit.C. A blood pressure of 220/120 mm Hg.D. The presence of bronchogenic carcinoma.10. The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The assistant places a gait belt around the clients waist prior to ambulating.B. The assistant places the client on the back with the clients head to the side.C. The assistant places her hand under the clients right axilla to help him/her move up in bed.D. The assistant praises the client for attempting to perform ADLs independently.

Answers : Neuro CVA(Stroke)1. 1. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction, so having suction equipment at the bedside is necessary. Padded tongue blades are safe to use. A toothbrush is appropriate to use.2. 3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.3. 3. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. A complete history is not possible in emergency care. Upcoming surgical procedures will need to be delay if t-PA is administered. Current medications are relevant, but onset of current stroke takes priority.4. 3. Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the clients ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.5. 2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. An echocardiogram is not needed for the client with a thrombotic stroke.6. 3. Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.7. 1. Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge verses intravenous. Beta blockers slow the heart rate and lower the blood pressure. Anti-hyperuricemic medication is given to clients with gout. Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at discharge.8. 1. Africana Americans have twice the rate of CVAs as Caucasians; males are more likely to have strokes than females except in advanced years. Orientals have a lower risk, possibly due to their high omega-3 fatty acids. Pregnancy is a minimal risk factor for CVA.9. 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the cranium. A bruit in the carotid artery would predispose a client to an embolic or ischemic stroke. High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic. Cancer is not a precursor to stroke.10. 3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. All the other actions are appropriate.

Neuro ICP, LOC,meningitis1) A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?1. Vomiting continues2. Intracranial pressure (ICP) is increased3. The client needs mechanical ventilation4. Blood is anticipated in the cerebralspinal fluid (CSF)2) A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?1. To reduce intraocular pressure2. To prevent acute tubular necrosis3. To promote osmotic diuresis to decrease ICP4. To draw water into the vascular system to increase blood pressure3) A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?1. Urine output increases2. Pupils are 8 mm and nonreactive3. Systolic blood pressure remains at 150 mm Hg4. BUN and creatinine levels return to normal4) Which of the following values is considered normal for ICP?1. 0 to 15 mm Hg2. 25 mm Hg3. 35 to 45 mm Hg4. 120/80 mm Hg5) Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?1. Ataxia and confusion2. Sodium depletion3. Tonic-clonic seizure4. Urinary incontinence6) Which of the following signs and symptoms of increased ICP after head trauma would appear first?1. Bradycardia2. Large amounts of very dilute urine3. Restlessness and confusion4. Widened pulse pressure7) Problems with memory and learning would relate to which of the following lobes?1. Frontal2. Occipital3. Parietal4. Temporal8) While cooking, your client couldnt feel the temperature of a hot oven. Which lobe could be dysfunctional?1. Frontal2. Occipital3. Parietal4. Temporal9) The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the clients peripheral response to pain?1. Sternal rub2. Pressure on the orbital rim3. Squeezing the sternocleidomastoid muscle4. Nail bed pressure10) The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?1. Side-lying, with legs pulled up and head bent down onto the chest2. Side-lying, with a pillow under the hip3. Prone, in a slight Trendelenburgs position4. Prone, with a pillow under the abdomen.11) A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:1. A cerebral lesion2. A temporal lesion3. An intact brainstem4. Brain death12) The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.13) The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:1. A positive Brudzinskis sign2. A negative Kernigs sign3. Absence of nuchal rigidity4. A Glascow Coma Scale score of 1514) A client is arousing from a coma and keeps saying, Just stop the pain. The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to:1. Tolerate the pain2. Decrease the perception of pain3. Escape the source of pain4. Divert attention from the source of pain.15) During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?1. Limiting conversation with the child2. Keeping extraneous noise to a minimum3. Allowing the child to play in the bathtub4. Performing treatments quickly16) Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?1. Hemorrhagic skin rash2. Edema3. Cyanosis4. Dyspnea on exertion17) When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis?1. Bladder infection2. Middle ear infection3. Fractured clavicle4. Septic arthritis18) The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.1. Head tilt2. Vomiting3. Polydipsia4. Lethargy5. Increased appetite6. Increased pulse19) A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis?1. Cloudy CSF, decreased protein, and decreased glucose2. Cloudy CSF, elevated protein, and decreased glucose3. Clear CSF, elevated protein, and decreased glucose4. Clear CSF, decreased pressure, and elevated protein20) A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?1. No precautions are required as long as antibiotics have been started2. Maintain enteric precautions3. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics4. Maintain neutropenic precautions21) A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present?1. Abnormal flexion of the upper extremities and extension of the lower extremities2. Rigid extension and pronation of the arms and legs3. Rigid pronation of all extremities4. Flaccid paralysis of all extremities22) Which of the following assessment data indicated nuchal rigidity?1. Positive Kernigs sign2. Negative Brudzinskis sign3. Positive homans sign4. Negative Kernigs sign23) Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions?1. Congenital anatomic abnormality of the meninges2. Lack of acquired resistance to the various etiologic organisms3. Occlusion or narrowing of the CSF pathway4. Natural affinity of the CNS to certain pathogens24) Which of the following pathologic processes is often associated with aseptic meningitis?1. Ischemic infarction of cerebral tissue2. Childhood diseases of viral causation such as mumps3. Brain abscesses caused by a variety of pyogenic organisms4. Cerebral ventricular irritation from a traumatic brain injury

ANSWERS : Neuro ICP, LOC,meningitis1. 2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isnt strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.2. 3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.3. 1. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.4. 1. Normal ICP is 0-15 mm Hg.5. 1. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesnt cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.6. 3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if theres damage to the posterior pituitary.7. 4. The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.8. 3. The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.9. 4. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.10. 1. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.11. 3. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.12. 2. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.13. 1. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinskis sign, and positive Kernigs sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernigs sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinskis sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.14. 3. The clients innate responses to pain are directed initially toward escaping from the source of pain. Variations in individuals tolerance and perception of pain are apparent only in conscious clients, and only conscious clients are able to employ distraction to help relieve pain.15. 2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.16. 1. DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.17. 2. Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumonococcus. A chronically draining ear is frequently also found.18. 1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.19. 2. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.20. 3. A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.21. 2. Decebrate posturing is characterized by the rigid extension and pronation of the arms and legs.22. 1. A positive Kernigs sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinskis sign is also indicative of the condition.23. 2. Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility.24. 2. Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia. Incidences of brain abscess are high in bacterial meningitis, and ischemic infarction of cerebral tissue can occur with tubercular meningitis. Traumatic brain injury could lead to bacterial (not viral) meningitis.

Meds for NeuroMannitol (Osmitrol) is used to decrease cerebral edema during increased ICP. It is an osmotic diuretic, which means the blood will be drawn from interstitial areas to vascular space and then be eliminated in the urine excretion. Electrolytes are also drawn into blood and excreted, so monitor for electrolyte imbalance Hyponatremia is a life threatening side effect, causes seizures and death. Maintain strict I&O. Can have rebound ICPs about 12 hours after drug administrationDobutamine (Dubutrex) and Norepinephrine (Levophed) cardiac stimulants used to maintain cerebral perfusion during increased ICP.Dexamethasone (Decadron) Corticosteroid used to decrease inflammation surrounding a brain tumor Used in medical management of meningitis. Used post craniotomy for cerebral edema Administer IV q 6 hours for 24-72 hours, change to oral a.s.a.p., taper dosage over 5-7 days As with any steroid, fluid retention, increased sugar, lowed immune system Common side effect nasal irritation, cardiovascular edema, hyperglycemia, cataract, oral candidiasis, impaired would healing If using with Mannitol (makes electrolytes be excreted) (by the way the two together are contraindicated according to the book) add potassium-rich foods or supplement to diet. Use good oral hygiene to prevent oral candidiasisPhenytion (Dilantin) Anticonvulsant to reduce risk of seizures Especially after supratentorial neurosurgical procedure (prone to seizures) Used to prevent grand mal and complex partial seizures During Ictal phase of seizure give ativan (lorazepam), then start dilantin Life threatening side effects are cardiovascular collapse, Agranulocytosis, aplastic anemias, dermatitis (bullous, exfoliative, or purpuric), Steven-Johnson syndrome. Common side effects gingival hyperplasia (swollen gums), give good mouth care. Self care pt should brush, floss and massage gums after each meal. Other side effect in power point; headache, dizziness, confusion, ataxia, slurred speech, depression, bleeding gums Decreases the effects of oral anticoagulants, corticosteroids, antihistamines, and oral contraceptive Therapeutic level is narrow; therapeutic level is 10-20 mcg/ml, toxic level is 30-50 mcg/ml, lethal level is 100 mcg/ml. Therapeutic levels not reached for at least 7-10 days Do not stop drug abruptly, may precipitate status epilepticus. Tell patients to inform all healthcare providers they are on this med.Diazepam (Valium) To reduce anxietyAntiseizure medications Tegretol Klonopin Keppra Luminal Dilantin-Phenytoin Topamax DepakoteAbortive meds for migraines Triptans Lilitrex amerge maxalt ergotamine cafergot-combo of ergotamine and caffeinePreventive meds for migraines Inderal Lopressor elavil valproate flunarzine serotonin antagonists Ca antagonistsApresoline Give for autonomic dysreflexiaTo give for bladder spasticity with spinal cord injury Baclofen, valium, DantriumFor encephalitis caused by Herpes Simplex Virus AcyclovirFor encephalitis caused by fungal infections AmphotericinFor complications of vasospasms after hemorrhagic stroke Calcium channel blockers Nimotop, Verapamil, Nifedipine OR triple H-therapy hemodilution, hypertension, hypervolemia (fluid volume expanders)Methylpredinisolone (Solu medoral) Give high doses of this steroid within 8 hours of spinal cord injury. Has shown to improve outcomes at 6 weeks, 6 months, and 1 yearFor shoulder pain after a stroke give: Lamictal Amitriptyline

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