ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 45 : Care of Critically Ill Patients with Neurologic Problems Questions
Question 1 of 5
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit sedation and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time.
Correct Answer: C
Rationale: The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a a skin breakdown, but it is not the immediate danger a brain infection would be.
Question 2 of 5
A nursing student studying the neurologic system learns which information? (Select all that apply.)
Correct Answer: A,C,D
Rationale: An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subbranchoid hemorrhage is usually caused by a ruptured aneurysm or AVM.
Question 3 of 5
The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)
Correct Answer: A,C,D,E
Rationale: An alcohol intake a high-fat diet. obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.
Question 4 of 5
A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive person and (UAP)? (Select all that apply.)
Correct Answer: B,E
Rationale: The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.
Question 5 of 5
A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)
Correct Answer: A,D,E
Rationale: Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thrombembolism. The client must be assigned for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.