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 nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH) Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and slight limp is not with a few priority for this referral.
Question 2 of 5
A client has a small-bore feeding tube (Dobboff tube) inserted for continuous external feedings while recovering from a traumatic serious injury. What actions should the nurse include to the clients care? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: All of these options are important for client safety when continuous external feedings are in use. Blue dye is not used for continuous a strong long injury is applied.
Question 3 of 5
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)
Correct Answer: A,B
Rationale: After a coil procedure, up to 20% of clients experience re-beding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.
Question 4 of 5
A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management (Select all that apply.)
Correct Answer: B,D,E
Rationale: Clients should take acetominopether for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motran), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client needs a thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.
Question 5 of 5
A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activity (t-PA) alphaing (Activase). The client weight is 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) mg
Correct Answer: A
Rationale: The client weighs 146 pounds, which is approximately 66.2 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg.
Therefore, 0.9 mg/kg ? 66.2 kg = 59.58 mg, which is less than the maximum dose of 90 mg. Thus, the client will receive 90 mg.