Nokea
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm slip on the clients record. What action by the nurse is best?
- A. Ask the client how long ago the clip was placed.
- B. Inform the provider about the aneurysm clip.
- C. Rescheduled the client for computed tomography.
- D. Assess the client for metal allergies.
Correct Answer: A
Rationale: Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is not the client. Informing the provider is important but determining the age of the clip is the first step. Rescheduling for a CT may not be necessary if the clip is MRI-compatible. Assessing for metal allergies is not relevant to MRI safety.
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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.
- A. Inability to communicate
- B. Nutritional deficit
- C. Risk for acquiring an infection
- D. Risk for skin breakdown
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.
A nursing student studying the neurologic system learns which information? (Select all that apply.)
- A. An aneurysm is a ballooning in a weakened part of an arterial wall.
- B. An arteriovenous malformation is the usual cause of the stroke.
- C. Intracerebral hemorrhage is bleeding directly into the brain.
- D. Reduced perfusion from vasospasm often makes stroke worse.
- E. Subarachnoid hemorrhage is caused by high blood pressure.
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.
A client is the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
- A. Ensure that informed consent is on the chart
- B. Document these findings in the client record.
- C. Give the prescribed/prorecedure/relation.
- D. Notify the provider of the findings immediately.
Correct Answer: D
Rationale: This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead is hesitation. Informed consent is needed for an LP. but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure/relation (or other preprocedure/mediations) should not be given as the LP will most likely be canceled.
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.)
- A. Discharging the client on a statin medication
- B. Providing the client with comprehensive therapies
- C. Meeting goals for nutrition within 1 week
- D. Providing and charting stroke education
- E. Preventing venous thrombembolism
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.
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
- A. Client with a core temperature of 95 F (35 C) for 2 days
- B. Client is a core for 2 weeks from a motor/ vehicle crash
- C. Client who is found unresponsive in a remote area of a field by a hunter
- D. Client with a systole blood/ pressure of 92 mm Hg since admission
Correct Answer: B
Rationale: In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near normal core temperature, 3) normal systolic blood pressure, and 4) a least one mentioned assessment. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client who is found unresponsive.