1 :

The client presented to the emergency department via EMS with reports of arm problems and a headache. The sudden headache was followed by loss of vision in the right eye for several seconds, right arm numbness, and weakness that started "20 minutes ago."

The client's condition seems to be deteriorating. He is now experiencing difficulty speaking and appears to be confused. His right arm weakness has progressed, and he is unable to lift it. He also reports a persistent headache that he rates as 7 on a scale of 0 to 10.

(1200hrs): The client's condition continues to worsen. He is now unresponsive to verbal stimuli and only responds to painful stimuli. His right arm and leg remain immobile. The headache persists, and he is now unable to communicate verbally. His family is present and very concerned about his condition.

(1100hrs)

 The client's right pupil is dilated and non-reactive to light. His speech is slurred, and he is unable to follow simple commands. His right arm shows no movement, and his right leg shows decreased movement. He is unable to smile symmetrically.

(1200hrs)

The client's right pupil remains dilated and non-reactive to light. He shows no response to verbal commands and only withdraws from painful stimuli. His right side remains immobile, and his facial droop has worsened.

(1100hrs)

CT scan: Shows a large area of decreased attenuation in the left hemisphere.

Blood glucose: 120 mg/dL

ECG: Shows atrial fibrillation

(1200hrs)

Repeat CT scan: Confirms large area of decreased attenuation in the left hemisphere with no evidence of hemorrhage.

Blood glucose: 118 mg/dL

ECG: Persistent atrial fibrillation

(1100hrs)

• Administer tissue plasminogen activator (tPA) if CT results are negative for hemorrhage.

• Start IV fluids.

• Monitor neurological status every 15 minutes.

(1200hrs)

• Continue monitoring neurological status every 15 minutes.

• Prepare for possible intubation if respiratory status declines.

• Administer antihypertensive medication to manage blood pressure.

 

Based on the client’s progression. Which of the following actions should the nurse take? Select all that apply:

Answer Options

Hint : Time-sensitive stroke treatment.

Correct Answers:

  • The nurse should prepare to administer tPA.
  • The nurse should anticipate the need for endotracheal intubation.
  • The nurse should prepare to administer antihypertensive medication
  • The nurse should use a calm and reassuring approach when interacting with the client.

Rationale :
Prepare to administer tPA CT confirms ischemic stroke (no hemorrhage), and tPA is standard treatment for ischemic stroke within the time window. Anticipate the need for endotracheal intubation: The client is unresponsive with worsening neurological status, risking airway compromise. Prepare to administer antihypertensive medication: The provider ordered BP management to prevent further stroke damage while maintaining perfusion. Use a calm and reassuring approach: The client is unresponsive, but the family is distressed; a calming presence reduces anxiety.
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2 :

Hint : Infection-induced brain swelling.

Correct Answers:

  • Cerebral edema is caused by the by-products of the pathogen that causes the meningitis.

Rationale :
Pathogens in meningitis trigger an inflammatory response, leading to capillary permeability and fluid accumulation in the brain. This swelling increases intracranial pressure (ICP), worsening symptoms.
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3 :

Hint : Pain from missing limb.

Correct Answers:

  • Neuropathic pain

Rationale :
Phantom limb pain is neuropathic because it results from damaged nerve pathways misfiring signals to the brain. Even though the limb is absent, the brain perceives pain due to abnormal nerve activity.
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4 :

Hint : Silent until rupture.

Correct Answers:

  • If you have a cerebral aneurysm, you typically will have no symptoms.

Rationale :
Most cerebral aneurysms remain asymptomatic until they rupture. If symptoms occur, they may include headache, visual disturbances, or neurological changes. Aneurysm rupture can lead to subarachnoid hemorrhage.
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5 :

Hint : affects thinking and movement.

Correct Answers:

  • Loss of sensation and cognition difficulties

Rationale :
Traumatic brain injuries (TBI) affect cognitive functions, memory, and motor skills. Clients may experience sensory loss, difficulty processing information, and personality changes. These secondary effects impact daily living.
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6 :

Hint : Alters behavior and emotions.

Correct Answers:

  • Changes to social cognition and challenges to inhibitory control

Rationale :
Neurological injuries can impair emotional regulation, impulse control, and social interactions. Clients may struggle with decision-making, frustration tolerance, and behavioral control. These changes affect rehabilitation.
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7 :

Hint : Checks for reduced brain circulation.

Correct Answers:

  • A CT angiogram will reveal any decreased blood flow related to vasospasm

Rationale :
CT angiography detects vasospasms, which can occur after a subarachnoid hemorrhage and restrict blood flow to the brain. Identifying vasospasms early prevents ischemic damage.
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8 :

Hint : Pain is seen, not spoken.

Correct Answers:

  • The patient grimaces when they move.

Rationale :
Objective signs of pain include facial expressions, guarding, and restlessness. Subjective signs include verbal reports of pain intensity. Grimacing is a nonverbal indicator of discomfort.
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9 :

Hint : ICP increase threatens brainstem.

Correct Answers:

  • Brainstem ischemia

Rationale :
Cushing’s Triad (hypertension, bradycardia, and irregular respirations) is a late sign of brainstem ischemia due to increased intracranial pressure. Without intervention, brain herniation may occur.
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10 :

Hint : pulls fluid out of brain tissue

Correct Answers:

  • Mannitol

Rationale :
Mannitol is an osmotic diuretic that draws fluid out of brain tissue, reducing intracranial pressure (ICP). It is commonly used in conditions like subarachnoid hemorrhage to manage cerebral edema and elevated ICP.
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Total Questions: 10

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