Nokea
A client is being prepared for a mechanical em/bolectomy. What action by the nurse takes priority?
- A. Assess for contraind/ications to/ fibrin/olytic
- B. Ensure that informed consent in on the chart.
- C. Ensure that informed consent is on the chart.
- D. The client is being informed consent.
- E. Review The clients medication lists.
Correct Answer: B
Rationale: For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibr/olytic/ytes are not used. A neurologic assessment and medication review are important, but the consent is the priority.
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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.)
- A. Alcohol intake.
- B. Alcohol intake.
- C. High-fat diet.
- D. Obesity.
- E. Smoking.
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.
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.)
- A. Assess neurologic status with the Glasgow Coma Scale.
- B. Check and document oxygen saturation every 1 to 2 hours.
- C. Check and document oxygen saturation every 1 to 2 hours.
- D. Elevate the head of the bed to 45 degrees to prevent aspiration.
- E. Elevate the head of the bed to 45 degrees to prevent aspiration.
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.
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.)
- A. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence.
- B. Client who had a cool procedure who says that there will be no problem following up for 1 year.
- C. Client who underwent a flow diversion procedure 3 months ago who is taking discontinue sodium (Colace) for constipation.
- D. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
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.
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 client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beat/min, pulse pressure increase from 26 to 40 min $\mathrm{Hg}$, and respiratory irregularities. What action by the nurse takes priority?
- A. Call the spouse of a Rapid Response Team.
- B. Increase the rate of the IV fluid administration.
- C. Notify respiratory therapy for a breathing treatment.
- D. Prepare to give IV pain medication.
Correct Answer: A
Rationale: These manifestations indicate Cushing syndrome, a potentially life-threatening increase in intracranial trauma (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment and pacion medication.