Which is the priority nursing intervention for a client admitted to the hospital with a brain attack

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Terms in this set (12)

Which lobe of the cerebrum includes the client's Broca's speech center?
1
Frontal lobe
2
Parietal lobe
3
Occipital lobe
4
Temporal lobe

1
Frontal lobe

A client with a brain attack (cerebrovascular accident) is admitted to the hospital. What is the priority nursing intervention for this client?
1
Changing position every two hours
2
Keeping a serial record of the pulse
3
Performing range-of-motion exercises
4
Monitoring for increased intracranial pressure

4
Monitoring for increased intracranial pressure

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response?
1
This is a way of getting attention that should be ignored.
2
The client can remember only depressing events from the past.
3
The client feels guilty about the demands being placed on the family.
4
This behavior is a common response over which the client has very little control.

4
This behavior is a common response over which the client has very little control.

If the client exhibits emotional instability, this usually is caused by lesions that affect the thalamic area in the part of the neural system most responsible for emotions.

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?
1
Increased serum glucose
2
Deficient renal perfusion
3
Inadequate antidiuretic hormone (ADH) secretion
4
Excess amounts of intravenous (IV) fluid

3
Inadequate antidiuretic hormone (ADH) secretion

Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced.

A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS). Which information should the nurse consider when planning care for this group of clients?
1
Progressive deterioration until death
2
Deficiencies of essential neurotransmitters
3
Increased risk for respiratory complications
4
Involuntary twitching of small muscle groups

3
Increased risk for respiratory complications

All three share increased risk for respiratory complications. As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration.

A preschool-aged child is about to be admitted to the pediatric intensive care unit after surgery for removal of a brain tumor. The nurse manager should intervene immediately when the child's nurse does what?
1
Places a hypothermia blanket at the bedside
2
Adjusts the bed to the Trendelenburg position
3
Obtains electronic equipment for monitoring of vital signs
4
Secures a pump to administer the ordered intravenous fluids

2
Adjusts the bed to the Trendelenburg position

What should the nurse include in the plan of care for a client with dementia of the Alzheimer type, stage 2 (moderate dementia)?
1
Discuss recent current events.
2
Teach the client new social skills.
3
Maintain a daily routine of living.
4
Encourage the client to talk about past experiences.

3
Maintain a daily routine of living.

What is a clinical manifestation of hypernatremia in burns?
1
Fatigue
2
Seizures
3
Paresthesias
4
Cardiac dysrhythmias

2
Seizures

Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

Which cerebral lobe includes the speech area that allows the client to process words into coherent thoughts?
1
Limbic lobe
2
Frontal lobe
3
Occipital lobe
4
Temporal

4
Temporal

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure?
1
Polyuria
2
Tachypnea
3
Increased restlessness
4
Intermittent tachycardia

3
Increased restlessness

What therapeutic effect does the nurse expect to identify when mannitol is administered parenterally to a client with cerebral edema?
1
Improved renal blood flow
2
Decreased intracranial pressure
3
Maintenance of circulatory volume
4
Prevention of the development of thrombi

2
Decreased intracranial pressure

Which type of cranial surgery involves opening the cranium and removing the bone flap?
1
Burr hole
2
Craniotomy
3
Craniectomy
4
Cranioplasty

2
Craniotomy

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