Nokea
The client being monitored while receiving tissue plasminogen activator (tPA) following an ischemic stroke opens both eyes spontaneously, mumbles inappropriate words in response to orientation questions, has no ability to move any extremities, and has decerebrate posturing in response to nailbed pressure. Based on the chart illustrated, what is the client’s Glasgow Coma Scale (GCS) score?
- A. 9 GCS score
Correct Answer: 9
Rationale: Spontaneous eye opening is scored as 4; the best verbal response of inappropriate words is scored as 3, and the best motor response of decerebrate posturing is scored as 2.
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The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?
- A. The client will return to work within six (6) months.
- B. The client is able to focus and stay on task for 10 minutes.
- C. The client will be able to dress self without assistance.
- D. The client will regain bowel and bladder control.
Correct Answer: B
Rationale: Cognitive deficits post-TBI may limit complex tasks. Focusing for 10 minutes (B) is a realistic short-term goal to build cognitive endurance. Returning to work (A) may be unrealistic within 6 months, dressing independently (C) requires motor and cognitive skills, and bowel/bladder control (D) may be affected by physical deficits.
When the nurse performs a physical assessment, which finding is most indicative of the client's disorder?
- A. Quivering eye movement
- B. Muscle spasms in the lower extremities
- C. Loss of motor function on the affected side
- D. Unilateral facial paralysis
Correct Answer: D
Rationale: Unilateral facial paralysis is the hallmark sign of Bell's palsy, caused by inflammation of cranial nerve VII.
The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
- A. Change in pupil size and reaction
- B. Sudden drop in the blood pressure
- C. Experiencing diminished sensation
- D. Change in the level of consciousness
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.
Which measure for preventing impaired skin integrity is appropriate to add to the care plan at this time?
- A. Use an air-fluidized (Clinitron) bed.
- B. Change the client's position every 2 hours.
- C. Rub any reddened areas every 2 hours.
- D. Provide daily treatment in a hyperbaric oxygen chamber.
Correct Answer: B
Rationale: Changing position every 2 hours prevents pressure ulcers in clients with MS who have weakness and numbness.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- A. Maintain the head of the bed at 60 degrees of elevation.
- B. Administer stool softeners daily.
- C. Ensure the pulse oximeter reading is higher than 93%.
- D. Perform deep nasal suction every two (2) hours.
- E. Administer mild sedatives.
Correct Answer: B,C
Rationale: Stool softeners (B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (C) ensures adequate oxygenation. High HOB elevation (A) may reduce cerebral perfusion, deep suction (D) risks increasing ICP, and sedatives (E) may mask neurological changes.