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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.
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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.
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (NAP) (Select all that apply.)
- A. Applying a cool washcloth to the head.
- B. Assitting the client to a position of comfort
- C. Keeping voices soft and soothing
- D. Maintaining low lighting in the room
- E. Providing antipyretics for fever
Correct Answer: A,B,C,D
Rationale: The client with meningitis often has high fever, pain, and some degree of confusion. Cool washclodts to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manager nurse. Key category low and light demand also helps convey caring in a nondroctioning manner. The nurse provides antipyretics for fever.
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.
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.