Neuro ICP, LOC, meningitis

1)
A client admitted to the hospital with a subarachnoid hemorrhage
has complaints of severe headache, nuchal rigidity, and projectile
vomiting. The nurse knows lumbar puncture (LP) would be
contraindicated in this client in which of the following circumstances?
1 Vomiting continues
2 Intracranial pressure (ICP) is increased
3 The client needs mechanical ventilation
4 Blood is anticipated in the cerebralspinal fluid (CSF)
2)
A client with a subdural hematoma becomes restless and
confused, with dilation of the ipsilateral pupil. The physician orders
mannitol for which of the following reasons?
1 To reduce intraocular pressure
2 To prevent acute tubular necrosis
3 To promote osmotic diuresis to decrease ICP
4 To draw water into the vascular system to increase blood
pressure
3)
A client with subdural hematoma was given mannitol to decrease
intracranial pressure (ICP). Which of the following results would best
show the mannitol was effective?
1 Urine output increases
2 Pupils are 8 mm and nonreactive
3 Systolic blood pressure remains at 150 mm Hg
4 BUN and creatinine levels return to normal
4)
Which of the following values is considered normal for ICP?
1 0 to 15 mm Hg
2 25 mm Hg
3 35 to 45 mm Hg
4 120/80 mm Hg
5)
Which of the following symptoms may occur with a phenytoin
level of 32 mg/dl?
1 Ataxia and confusion
2 Sodium depletion
3 Tonic-clonic seizure
4 Urinary incontinence
6)
Which of the following signs and symptoms of increased ICP after
head trauma would appear first?
1 Bradycardia
2 Large amounts of very dilute urine
3 Restlessness and confusion
4 Widened pulse pressure
7)
Problems with memory and learning would relate to which of the
following lobes?
1 Frontal
2 Occipital
3 Parietal

4 Temporal
8)
While cooking, your client couldnt feel the temperature of a hot
oven. Which lobe could be dysfunctional?
1 Frontal
2 Occipital
3 Parietal
4 Temporal
9)
The nurse is assessing the motor function of an unconscious
client. The nurse would plan to use which of the following to test the
clients peripheral response to pain?
1 Sternal rub
2 Pressure on the orbital rim
3 Squeezing the sternocleidomastoid muscle
4 Nail bed pressure
10) The client is having a lumbar puncture performed. The nurse
would plan to place the client in which position for the procedure?
1 Side-lying, with legs pulled up and head bent down onto the
chest
2 Side-lying, with a pillow under the hip
3 Prone, in a slight Trendelenburgs position
4 Prone, with a pillow under the abdomen.
11) A nurse is assisting with caloric testing of the oculovestibular
reflex of an unconscious client. Cold water is injected into the left
auditory canal. The client exhibits eye conjugate movements toward
the left followed by a rapid nystagmus toward the right. The nurse
understands that this indicates the client has:
1 A cerebral lesion
2 A temporal lesion
3 An intact brainstem
4 Brain death
12) The nurse is caring for the client with increased intracranial
pressure. The nurse would note which of the following trends in vital
signs if the ICP is rising?
1 Increasing temperature, increasing pulse, increasing respirations,
decreasing blood pressure.
2 Increasing temperature, decreasing pulse, decreasing
respirations, increasing blood pressure.
3 Decreasing temperature, decreasing pulse, increasing
respirations, decreasing blood pressure.
4 Decreasing temperature, increasing pulse, decreasing
respirations, increasing blood pressure.
13) The nurse is evaluating the status of a client who had a
craniotomy 3 days ago. The nurse would suspect the client is
developing meningitis as a complication of surgery if the client
exhibits:
1 A positive Brudzinskis sign

2 A negative Kernigs sign

3 Absence of nuchal rigidity
4 A Glascow Coma Scale score of 15
14) A client is arousing from a coma and keeps saying, Just stop the
pain. The nurse responds based on the knowledge that the human
body typically and automatically responds to pain first with attempts
to:
1 Tolerate the pain
2 Decrease the perception of pain
3 Escape the source of pain
4 Divert attention from the source of pain.
15) During the acute stage of meningitis, a 3-year-old child is restless
and irritable. Which of the following would be most appropriate to
institute?
1 Limiting conversation with the child
2 Keeping extraneous noise to a minimum
3 Allowing the child to play in the bathtub
4 Performing treatments quickly
16) Which of the following would lead the nurse to suspect that a child
with meningitis has developed disseminated intravascular coagulation?
1 Hemorrhagic skin rash
2 Edema
3 Cyanosis
4 Dyspnea on exertion
17) When interviewing the parents of a 2-year-old child, a history of
which of the following illnesses would lead the nurse to suspect
pneumococcal meningitis?
1 Bladder infection
2 Middle ear infection
3 Fractured clavicle
4 Septic arthritis
18) The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the child
to demonstrate? Select all that apply.
1 Head tilt
2 Vomiting
3 Polydipsia
4 Lethargy
5 Increased appetite
6 Increased pulse
19) A lumbar puncture is performed on a child suspected of having
bacterial meningitis. CSF is obtained for analysis. A nurse reviews the
results of the CSF analysis and determines that which of the following
results would verify the diagnosis?
1 Cloudy CSF, decreased protein, and decreased glucose
2 Cloudy CSF, elevated protein, and decreased glucose

3 Clear CSF, elevated protein, and decreased glucose

4 Clear CSF, decreased pressure, and elevated protein
20) A nurse is planning care for a child with acute bacterial meningitis.
Based on the mode of transmission of this infection, which of the
following would be included in the plan of care?
1 No precautions are required as long as antibiotics have been
started
2 Maintain enteric precautions
3 Maintain respiratory isolation precautions for at least 24 hours
after the initiation of antibiotics
4 Maintain neutropenic precautions
21) A nurse is reviewing the record of a child with increased ICP and
notes that the child has exhibited signs of decerebrate posturing. On
assessment of the child, the nurse would expect to note which of the
following if this type of posturing was present?
1 Abnormal flexion of the upper extremities and extension of the
lower extremities
2 Rigid extension and pronation of the arms and legs
3 Rigid pronation of all extremities
4 Flaccid paralysis of all extremities
22) Which of the following assessment data indicated nuchal rigidity?
1 Positive Kernigs sign
2 Negative Brudzinskis sign
3 Positive homans sign
4 Negative Kernigs sign
23) Meningitis occurs as an extension of a variety of bacterial
infections due to which of the following conditions?
1 Congenital anatomic abnormality of the meninges
2 Lack of acquired resistance to the various etiologic organisms
3 Occlusion or narrowing of the CSF pathway
4 Natural affinity of the CNS to certain pathogens
24) Which of the following pathologic processes is often associated
with aseptic meningitis?
1 Ischemic infarction of cerebral tissue
2 Childhood diseases of viral causation such as mumps
3 Brain abscesses caused by a variety of pyogenic organisms
4 Cerebral ventricular irritation from a traumatic brain injury
ANSWERS
1 2. Sudden removal of CSF results in pressures lower in the
lumbar area than the brain and favors herniation of the brain;
therefore, LP is contraindicated with increased ICP. Vomiting may
be caused by reasons other than increased ICP; therefore, LP
isnt strictly contraindicated. An LP may be preformed on clients
needing mechanical ventilation. Blood in the CSF is diagnostic for
subarachnoid hemorrhage and was obtained before signs and
symptoms of ICP.

2 3. Mannitol promotes osmotic diuresis by increasing the pressure

gradient, drawing fluid from intracellular to intravascular spaces.
Although mannitol is used for all the reasons described, the
reduction of ICP in this client is a concern.
3 1. Mannitol promotes osmotic diuresis by increasing the pressure
gradient in the renal tubes. Fixed and dilated pupils are
symptoms of increased ICP or cranial nerve damage. No
information is given about abnormal BUN and creatinine levels or
that mannitol is being given for renal dysfunction or blood
pressure maintenance.
4 1. Normal ICP is 0-15 mm Hg.
5 1. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32
mg/dl indicates toxicity. Symptoms of toxicity include confusion
and ataxia. Phenytoin doesnt cause hyponatremia, seizure, or
urinary incontinence. Incontinence may occur during or after a
seizure.
6 3. The earliest symptom of elevated ICP is a change in mental
status. Bradycardia, widened pulse pressure, and bradypnea
occur later. The client may void large amounts of very dilute
urine if theres damage to the posterior pituitary.
7 4. The temporal lobe functions to regulate memory and learning
problems because of the integration of the hippocampus. The
frontal lobe primarily functions to regulate thinking, planning,
and judgment. The occipital lobe functions regulate vision. The
parietal lobe primarily functions with sensory function.
8 3. The parietal lobe regulates sensory function, which would
include the ability to sense hot or cold objects. The frontal lobe
regulates thinking, planning, and judgment, and the occipital
lobe is primarily responsible for vision function. The temporal
lobe regulates memory.
9 4. Motor testing on the unconscious client can be done only by
testing response to painful stimuli. Nailbed pressure tests a basic
peripheral response. Cerebral responses to pain are testing using
sternal rub, placing upward pressure on the orbital rim, or
squeezing the clavicle or sternocleidomastoid muscle.
10. 1. The client undergoing lumbar puncture is positioned lying on
the side, with the legs pulled up to the abdomen, and with the head
bent down onto the chest. This position helps to open the spaces
between the vertebrae.
11. 3. Caloric testing provides information about differentiating
between cerebellar and brainstem lesions. After determining patency
of the ear canal, cold or warm water is injected in the auditory canal. A
normal response that indicates intact function of cranial nerves III, IV,
and VIII is conjugate eye movements toward the side being irrigated,
followed by rapid nystagmus to the opposite side. Absent or
dysconjugate eye movements indicate brainstem damage.

12. 2. A change in vital signs may be a late sign of increased

intracranial pressure. Trends include increasing temperature and blood
pressure and decreasing pulse and respirations. Respiratory
irregularities also may arise.
13. 1. Signs of meningeal irritation compatible with meningitis include
nuchal rigidity, positive Brudzinskis sign, and positive Kernigs sign.
Nuchal rigidity is characterized by a stiff neck and soreness, which is
especially noticeable when the neck is fixed. Kernigs sign is positive
when the client feels pain and spasm of the hamstring muscles when
the knee and thigh are extended from a flexed-right angle position.
Brudzinskis sign is positive when the client flexes the hips and knees
in response to the nurse gently flexing the head and neck onto the
chest. A Glascow Coma Scale of 15 is a perfect score and indicates the
client is awake and alert with no neurological deficits.
14. 3. The clients innate responses to pain are directed initially
toward escaping from the source of pain. Variations in individuals
tolerance and perception of pain are apparent only in conscious clients,
and only conscious clients are able to employ distraction to help
relieve pain.
15. 2. A child in the acute stage of meningitis is irritable and
hypersensitive to loud noise and light. Therefore, extraneous noise
should be minimized and bright lights avoided as much as possible.
There is no need to limit conversations with the child. However, the
nurse should speak in a calm, gentle, reassuring voice. The child needs
gentle and calm bathing. Because of the acuteness of the infection,
sponge baths would be more appropriate than tub baths. Although
treatments need to be completed as quickly as possible to prevent
overstressing the child, any treatments should be performed carefully
and at a pace that avoids sudden movements to prevent startling the
child and subsequently increasing intracranial pressure.
16. 1. DIC is characterized by skin petechiae and a purpuric skin rash
caused by spontaneous bleeding into the tissues. An abnormal
coagulation phenomenon causes the condition.
17. 2. Organisms that cause bacterial meningitis, such as
pneumococci or meningococci, are commonly spread in the body by
vascular dissemination from a middle ear infection. The meningitis may
also be a direct extension from the paranasal and mastoid sinuses. The
causative organism is a pneumonococcus. A chronically draining ear is
frequently also found.
18. 1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed
in a child with a brain tumor. Clinical manifestations are the result of
location and size of the tumor.
19. 2. A diagnosis of meningitis is made by testing CSF obtained by
lumbar puncture. In the case of bacterial meningitis, findings usually
include an elevated pressure, turbid or cloudy CSF, elevated
leukocytes, elevated protein, and decreased glucose levels.

20. 3. A major priority of nursing care for a child suspected of having

meningitis is to administer the prescribed antibiotic as soon as it is
ordered. The child is also placed on respiratory isolation for at least 24
hours while culture results are obtained and the antibiotic is having an
effect.
21. 2. Decebrate posturing is characterized by the rigid extension and
pronation of the arms and legs.
22. 1. A positive Kernigs sign indicated nuchal rigidity, caused by an
irritative lesion of the subarachnoid space. Brudzinskis sign is also
indicative of the condition.
23. 2. Extension of a variety of bacterial infections is a major causative
factor of meningitis and occurs as a result of a lack of acquired
resistance to the etiologic organisms. Preexisting CNS anomalies are
factors that contribute to susceptibility.
24. 2. Aseptic meningitis is caused principally by viruses and is often
associated with other diseases such as measles, mumps, herpes, and
leukemia. Incidences of brain abscess are high in bacterial meningitis,
and ischemic infarction of cerebral tissue can occur with tubercular
meningitis. Traumatic brain injury could lead to bacterial (not viral)
meningitis.
Neuro Seizures
1)
An 18-year-old client is admitted with a closed head injury
sustained in a MVA. His intracranial pressure (ICP) shows an upward
trend. Which intervention should the nurse perform first?
5 Reposition the client to avoid neck flexion
6 Administer 1 g Mannitol IV as ordered
7 Increase the ventilators respiratory rate to 20 breaths/minute
8 Administer 100mg of pentobarbital IV as ordered.
2)
A client with a subarachnoid hemorrhage is prescribed a 1,000mg loading dose of Dilantin IV. Which consideration is most important
when administering this dose?
5 Therapeutic drug levels should be maintained between 20 to 30
mg/ml.
6 Rapid dilantin administration can cause cardiac arrhythmias.
7 Dilantin should be mixed in dextrose in water before
administration.
8 Dilantin should be administered through an IV catheter in the
clients hand.
3)
A client with head trauma develops a urine output of 300 ml/hr,
dry skin, and dry mucous membranes. Which of the following nursing
interventions is the most appropriate to perform initially?
5 Evaluate urine specific gravity
6 Anticipate treatment for renal failure
7 Provide emollients to the skin to prevent breakdown
8 Slow down the IV fluids and notify the physician

4)
When evaluating an ABG from a client with a subdural
hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the
following responses best describes this result?
5 Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP).
6 Emergent; the client is poorly oxygenated.
7 Normal
8 Significant; the client has alveolar hypoventilation.
5)
A client who had a transsphenoidal hypophysectomy should be
watched carefully for hemorrhage, which may be shown by which of
the following signs?
5 Bloody drainage from the ears
6 Frequent swallowing
7 Guaiac-positive stools
8 Hematuria
6)
After a hypophysectomy, vasopressin is given IM for which of the
following reasons?
5 To treat growth failure
6 To prevent syndrome of inappropriate antidiuretic hormone
(SIADH)
7 To reduce cerebral edema and lower intracranial pressure
8 To replace antidiuretic hormone (ADH) normally secreted by the
pituitary.
7)
A client comes into the ER after hitting his head in an MVA. Hes
alert and oriented. Which of the following nursing interventions should
be done first?
5 Assess full ROM to determine extent of injuries
6 Call for an immediate chest x-ray
7 Immobilize the clients head and neck
8 Open the airway with the head-tilt chin-lift maneuver
8)
A client with a C6 spinal injury would most likely have which of
the following symptoms?
5 Aphasia
6 Hemiparesis
7 Paraplegia
8 Tetraplegia
9)
A 30-year-old was admitted to the progressive care unit with a C5
fracture from a motorcycle accident. Which of the following
assessments would take priority?
5 Bladder distension
6 Neurological deficit
7 Pulse ox readings
8 The clients feelings about the injury
10) While in the ER, a client with C8 tetraplegia develops a blood
pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of
the following conditions?

5 Autonomic dysreflexia
6 Hemorrhagic shock
7 Neurogenic shock
8 Pulmonary embolism
11) A client is admitted with a spinal cord injury at the level of T12. He
has limited movement of his upper extremities. Which of the following
medications would be used to control edema of the spinal cord?
5 Acetazolamide (Diamox)
6 Furosemide (Lasix)
7 Methylprednisolone (Solu-Medrol)
8 Sodium bicarbonate
12) A 22-year-old client with quadriplegia is apprehensive and flushed,
with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of
the following nursing interventions should be done first?
5 Place the client flat in bed
6 Assess patency of the indwelling urinary catheter
7 Give one SL nitroglycerin tablet
8 Raise the head of the bed immediately to 90 degrees
13) A client with a cervical spine injury has Gardner-Wells tongs
inserted for which of the following reasons?
5 To hasten wound healing
6 To immobilize the surgical spine
7 To prevent autonomic dysreflexia
8 To hold bony fragments of the skull together
14) Which of the following interventions describes an appropriate
bladder program for a client in rehabilitation for spinal cord injury?
5 Insert an indwelling urinary catheter to straight drainage
6 Schedule intermittent catherization every 2 to 4 hours
7 Perform a straight catherization every 8 hours while awake
8 Perform Credes maneuver to the lower abdomen before the
client voids.
15) A client is admitted to the ER for head trauma is diagnosed with
an epidural hematoma. The underlying cause of epidural hematoma is
usually related to which of the following conditions?
5 Laceration of the middle meningeal artery
6 Rupture of the carotid artery
7 Thromboembolism from a carotid artery
8 Venous bleeding from the arachnoid space
16) A 23-year-old client has been hit on the head with a baseball bat.
The nurse notes clear fluid draining from his ears and nose. Which of
the following nursing interventions should be done first?
5 Position the client flat in bed
6 Check the fluid for dextrose with a dipstick
7 Suction the nose to maintain airway patency
8 Insert nasal and ear packing with sterile gauze

17) When discharging a client from the ER after a head trauma, the
nurse teaches the guardian to observe for a lucid interval. Which of the
following statements best described a lucid interval?
5 An interval when the clients speech is garbled
6 An interval when the client is alert but cant recall recent events
7 An interval when the client is oriented but then becomes
somnolent
8 An interval when the client has a warning symptom, such as an
odor or visual disturbance.
18) Which of the following clients on the rehab unit is most likely to
develop autonomic dysreflexia?
7 A client with a brain injury
8 A client with a herniated nucleus pulposus
9 A client with a high cervical spine injury
10 A client with a stroke
19) Which of the following conditions indicates that spinal shock is
resolving in a client with C7 quadriplegia?
5 Absence of pain sensation in chest
6 Spasticity
7 Spontaneous respirations
8 Urinary continence
20) A nurse assesses a client who has episodes of autonomic
dysreflexia. Which of the following conditions can cause autonomic
dysreflexia?
5 Headache
6 Lumbar spinal cord injury
7 Neurogenic shock
8 Noxious stimuli
21) During an episode of autonomic dysreflexia in which the client
becomes hypertensive, the nurse should perform which of the
following interventions?
5 Elevate the clients legs
6 Put the client flat in bed
7 Put the client in the Trendelenburgs position
8 Put the client in the high-Fowlers position
22) A client with a T1 spinal cord injury arrives at the emergency
department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis
of the lower extremities. Which of the following conditions would most
likely be suspected?
5 Autonomic dysreflexia
6 Hypervolemia
7 Neurogenic shock
8 Sepsis
23) A client has a cervical spine injury at the level of C5. Which of the
following conditions would the nurse anticipate during the acute
phase?

5 Absent corneal reflex

6 Decerebate posturing
7 Movement of only the right or left half of the body
8 The need for mechanical ventilation
24) A client with C7 quadriplegia is flushed and anxious and complains
of a pounding headache. Which of the following symptoms would also
be anticipated?
5 Decreased urine output or oliguria
6 Hypertension and bradycardia
7 Respiratory depression
8 Symptoms of shock
25) A 40-year-old paraplegic must perform intermittent catherization
of the bladder. Which of the following instructions should be given?
10 Clean the meatus from back to front.
11 Measure the quantity of urine.
12 Gently rotate the catheter during removal.
13 Clean the meatus with soap and water.
26) An 18-year-old client was hit in the head with a baseball during
practice. When discharging him to the care of his mother, the nurse
gives which of the following instructions?
1 Watch him for keyhole pupil the next 24 hours.
2 Expect profuse vomiting for 24 hours after the injury.
3 Wake him every hour and assess his orientation to person, time,
and place.
4 Notify the physician immediately if he has a headache.
27) Which neurotransmitter is responsible for may of the functions of
the frontal lobe?
1 Dopamine
2 GABA
3 Histamine
4 Norepinephrine
28) The nurse is discussing the purpose of an electroencephalogram
(EEG) with the family of a client with massive cerebral hemorrhage and
loss of consciousness. It would be most accurate for the nurse to tell
family members that the test measures which of the following
conditions?
1 Extent of intracranial bleeding
2 Sites of brain injury
3 Activity of the brain
4 Percent of functional brain tissue
29) A client arrives at the ER after slipping on a patch of ice and
hitting her head. A CT scan of the head shows a collection of blood
between the skull and dura mater. Which type of head injury does this
finding suggest?
1 Subdural hematoma
2 Subarachnoid hemorrhage

3 Epidural hematoma
4 Contusion
30) After falling 20, a 36-year-old man sustains a C6 fracture with
spinal cord transaction. Which other findings should the nurse expect?
1 Quadriplegia with gross arm movement and diaphragmic
breathing
2 Quadriplegia and loss of respiratory function
3 Paraplegia with intercostal muscle loss
4 Loss of bowel and bladder control
31) A 20-year-old client who fell approximately 30 is unresponsive and
breathless. A cervical spine injury is suspected. How should the firstresponder open the clients airway for rescue breathing?
1 By inserting a nasopharyngeal airway
2 By inserting a oropharyngeal airway
3 By performing a jaw-thrust maneuver
4 By performing the head-tilt, chin-lift maneuver
32) The nurse is caring for a client with a T5 complete spinal cord
injury. Upon assessment, the nurse notes flushed skin, diaphoresis
above the T5, and a blood pressure of 162/96. The client reports a
severe, pounding headache. Which of the following nursing
interventions would be appropriate for this client? Select all that apply.
1 Elevate the HOB to 90 degrees
2 Loosen constrictive clothing
3 Use a fan to reduce diaphoresis
4 Assess for bladder distention and bowel impaction
5 Administer antihypertensive medication
6 Place the client in a supine position with legs elevated
33) The client with a head injury has been urinating copious amounts
of dilute urine through the Foley catheter. The clients urine output for
the previous shift was 3000 ml. The nurse implements a new physician
order to administer:
1 Desmopressin (DDAVP, stimate)
2 Dexamethasone (Decadron)
3 Ethacrynic acid (Edecrin)
4 Mannitol (Osmitrol)
34) The nurse is caring for the client in the ER following a head injury.
The client momentarily lost consciousness at the time of the injury and
then regained it. The client now has lost consciousness again. The
nurse takes quick action, knowing this is compatible with:
1 Skull fracture
2 Concussion
3 Subdural hematoma
4 Epidural hematoma
35) The nurse is caring for a client who suffered a spinal cord injury 48
hours ago. The nurse monitors for GI complications by assessing for:
1 A flattened abdomen

2 Hematest positive nasogastric tube drainage

3 Hyperactive bowel sounds
4 A history of diarrhea
36) A client with a spinal cord injury is prone to experiencing
autonomic dysreflexia. The nurse would avoid which of the following
measures to minimize the risk of recurrence?
1 Strict adherence to a bowel retraining program
2 Limiting bladder catherization to once every 12 hours
3 Keeping the linen wrinkle-free under the client
4 Preventing unnecessary pressure on the lower limbs
37) The nurse is planning care for the client in spinal shock. Which of
the following actions would be least helpful in minimizing the effects of
vasodilation below the level of the injury?
1 Monitoring vital signs before and during position changes
2 Using vasopressor medications as prescribed
3 Moving the client quickly as one unit
4 Applying Teds or compression stockings.
38) The nurse is caring for a client admitted with spinal cord injury.
The nurse minimizes the risk of compounding the injury most
effectively by:
1 Keeping the client on a stretcher
2 Logrolling the client on a firm mattress
3 Logrolling the client on a soft mattress
4 Placing the client on a Stryker frame
39) The nurse is evaluating neurological signs of the male client in
spinal shock following spinal cord injury. Which of the following
observations by the nurse indicates that spinal shock persists?
1 Positive reflexes
2 Hyperreflexia
3 Inability to elicit a Babinskis reflex
4 Reflex emptying of the bladder
40) A client with a spinal cord injury suddenly experiences an episode
of autonomic dysreflexia. After checking the clients vital signs, list in
order of priority, the nurses actions (Number 1 being the first priority
and number 5 being the last priority).
1 Check for bladder distention
2 Raise the head of the bed
3 Contact the physician
4 Loosen tight clothing on the client
5 Administer an antihypertensive medication
41) A client is at risk for increased ICP. Which of the following would be
a priority for the nurse to monitor?
1 Unequal pupil size
2 Decreasing systolic blood pressure
3 Tachycardia
4 Decreasing body temperature

42) Which of the following respiratory patterns indicate increasing ICP

in the brain stem?
1 Slow, irregular respirations
2 Rapid, shallow respirations
3 Asymmetric chest expansion
4 Nasal flaring
43) Which of the following nursing interventions is appropriate for a
client with an ICP of 20 mm Hg?
1 Give the client a warming blanket
2 Administer low-dose barbiturate
3 Encourage the client to hyperventilate
4 Restrict fluids
44) A client has signs of increased ICP. Which of the following is an
early indicator of deterioration in the clients condition?
1 Widening pulse pressure
2 Decrease in the pulse rate
3 Dilated, fixed pupil
4 Decrease in LOC
45) A client who is regaining consciousness after a craniotomy
becomes restless and attempts to pull out her IV line. Which nursing
intervention protects the client without increasing her ICP?
1 Place her in a jacket restraint
2 Wrap her hands in soft mitten restraints
3 Tuck her arms and hands under the draw sheet
4 Apply a wrist restraint to each arm
46) Which of the following describes decerebrate posturing?
1 Internal rotation and adduction of arms with flexion of elbows,
wrists, and fingers
2 Back hunched over, rigid flexion of all four extremities with
supination of arms and plantar flexion of the feet
3 Supination of arms, dorsiflexion of feet
4 Back arched; rigid extension of all four extremities.
47) A client receiving vent-assisted mode ventilation begins to
experience cluster breathing after recent intracranial occipital
bleeding. Which action would be most appropriate?
1 Count the rate to be sure the ventilations are deep enough to be
sufficient
2 Call the physician while another nurse checks the vital signs and
ascertains the patients Glasgow Coma score.
3 Call the physician to adjust the ventilator settings.
4 Check deep tendon reflexes to determine the best motor
response
48) In planning the care for a client who has had a posterior fossa
(infratentorial) craniotomy, which of the following is contraindicates
when positioning the client?
1 Keeping the client flat on one side or the other

2 Elevating the head of the bed to 30 degrees

3 Log rolling or turning as a unit when turning
4 Keeping the head in neutral position
49) A client has been pronounced brain dead. Which findings would
the nurse assess? Check all that apply.
1 Decerebrate posturing
2 Dilated non reactive pupils
3 Deep tendon reflexes
4 Absent corneal reflex
ANSWERS
1 1. The nurse should first attempt nursing interventions, such as
repositioning the client to avoid neck flexion, which increases
venous return and lowers ICP. If nursing measures prove
ineffective, notify the physician, who may prescribe mannitol,
pentobarbital, or hyperventilation therapy.
2 2. Dilantin IV shouldnt be given at a rate exceeding 50
mg/minute. Rapid administration can depress the myocardium,
causing arrhythmias. Therapeutic drug levels range from 10 to
20 mg/ml. Dilantin shouldnt be mixed in solution for
administration. However, because its compatible with normal
saline solution, it can be injected through an IV line containing
normal saline. When given through an IV catheter hand, dilantin
may cause purple glove syndrome.
3 1. Urine output of 300 ml/hr may indicate diabetes insipidus,
which is a failure of the pituitary to produce anti-diuretic
hormone. This may occur with increased intracranial pressure
and head trauma; the nurse evaluates for low urine specific
gravity, increased serum osmolarity, and dehydration. Theres no
evidence that the client is experiencing renal failure. Providing
emollients to prevent skin breakdown is important, but doesnt
need to be performed immediately. Slowing the rate of IV fluid
would contribute to dehydration when polyuria is present.
4 1. A normal PaCO2 value is 35 to 45 mm Hg. CO2 has
vasodilating properties; therefore, lowering PaCO2 through
hyperventilation will lower ICP caused by dilated cerebral
vessels. Oxygenation is evaluated through PaO2 and oxygen
saturation. Alveolar hypoventilation would be reflected in an
increased PaCO2.
5 2. Frequent swallowing after brain surgery may indicate fluid or
blood leaking from the sinuses into the oropharynx. Blood or fluid
draining from the ear may indicate a basilar skull fracture.
6 4. After hypophysectomy, or removal of the pituitary gland, the
body cant synthesize ADH. Somatropin or growth hormone, not
vasopressin is used to treat growth failure. SIADH results from
excessive ADH secretion. Mannitol or corticosteroids are used to
decrease cerebral edema.

7 3. All clients with a head injury are treated as if a cervical spine

injury is present until x-rays confirm their absence. ROM would
be contraindicated at this time. There is no indication that the
client needs a chest x-ray. The airway doesnt need to be opened
since the client appears alert and not in respiratory distress. In
addition, the head-tilt chin-lift maneuver wouldnt be used until
the cervical spine injury is ruled out.
8 4. Tetraplegia occurs as a result of cervical spine injuries.
Paraplegia occurs as a result of injury to the thoracic cord and
below.
9 3. After a spinal cord injury, ascending cord edema may cause a
higher level of injury. The diaphragm is innervated at the level of
C4, so assessment of adequate oxygenation and ventilation is
necessary. Although the other options would be necessary at a
later time, observation for respiratory failure is the priority.
10. 3. Symptoms of neurogenic shock include hypotension,
bradycardia, and warm, dry skin due to the loss of adrenergic
stimulation below the level of the lesion. Hypertension, bradycardia,
flushing, and sweating of the skin are seen with autonomic dysreflexia.
Hemorrhagic shock presents with anxiety, tachycardia, and
hypotension; this wouldnt be suspected without an injury. Pulmonary
embolism presents with chest pain, hypotension, hypoxemia,
tachycardia, and hemoptysis; this may be a later complication of spinal
cord injury due to immobility.
11. 3. High doses of Solu-Medrol are used within 24 hours of spinal
injury to reduce cord swelling and limit neurological deficit. The other
drugs arent indicated in this circumstance.
12. 4. Anxiety, flushing above the level of the lesion, piloerection,
hypertension, and bradycardia are symptoms of autonomic dysreflexia,
typically caused by such noxious stimuli such as a full bladder, fecal
impaction, or decubitus ulcer. Putting the client flat will cause the blood
pressure to increase even more. The indwelling urinary catheter should
be assessed immediately after the HOB is raised. Nitroglycerin is given
to reduce chest pain and reduce preload; it isnt used for hypertension
or dysreflexia.
13. 2. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine
until surgical stabilization is accomplished.
14. 2. Intermittent catherization should begin every 2 to 4 hours early
in the treatment. When residual volume is less than 400 ml, the
schedule may advance to every 4 to 6 hours. Indwelling catheters may
predispose the client to infection and are removed as soon as possible.
Credes maneuver is not used on people with spinal cord injury.
15. 1. Epidural hematoma or extradural hematoma is usually caused
by laceration of the middle meningeal artery. An embolic stroke is a
thromboembolism from a carotid artery that ruptures. Venous bleeding
from the arachnoid space is usually observed with subdural hematoma.

16. 2. Clear fluid from the nose or ear can be determined to be

cerebral spinal fluid or mucous by the presence of dextrose. Placing the
client flat in bed may increase ICP and promote pulmonary aspiration.
The nose wouldnt be suctioned because of the risk for suctioning brain
tissue through the sinuses. Nothing is inserted into the ears or nose of
a client with a skull fracture because of the risk of infection.
17. 3. A lucid interval is described as a brief period of unconsciousness
followed by alertness; after several hours, the client again loses
consciousness. Garbled speech is known as dysarthria. An interval in
which the client is alert but cant recall recent events is known as
amnesia. Warning symptoms or auras typically occur before seizures.
18. 3. Autonomic dysreflexia refers to uninhibited sympathetic outflow
in clients with spinal cord injuries about the level of T10. The other
clients arent prone to dysreflexia.
19. 3. Spasticity, the return of reflexes, is a sign of resolving shock.
Spinal or neurogenic shock is characterized by hypotension,
bradycardia, dry skin, flaccid paralysis, or the absence of reflexes
below the level of injury. The absence of pain sensation in the chest
doesnt apply to spinal shock. Spinal shock descends from the injury,
and respiratory difficulties occur at C4 and above.
20. 4. Noxious stimuli, such as a full bladder, fecal impaction, or a
decub ulcer, may cause autonomic dysreflexia. A headache is a
symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia
is most commonly seen with injuries at T10 or above. Neurogenic
shock isnt a cause of dysreflexia.
21. 4. Putting the client in the high-Fowlers position will decrease
cerebral blood flow, decreasing hypertension. Elevating the clients
legs, putting the client flat in bed, or putting the bed in the
Trendelenburgs position places the client in positions that improve
cerebral blood flow, worsening hypertension.
22. 3. Loss of sympathetic control and unopposed vagal stimulation
below the level of injury typically cause hypotension, bradycardia,
pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic
shock. Hypervolemia is indicated by rapid and bounding pulse and
edema. Autonomic dysreflexia occurs after neurogenic shock abates.
Signs of sepsis would include elevated temperature, increased heart
rate, and increased respiratory rate.
23. 4. The diaphragm is stimulated by nerves at the level of C4.
Initially, this client may need mechanical ventilation due to cord
edema. This may resolve in time. Absent corneal reflexes, decerebate
posturing, and hemiplegia occur with brain injuries, not spinal cord
injuries.
24. 2. Hypertension, bradycardia, anxiety, blurred vision, and flushing
above the lesion occur with autonomic dysreflexia due to uninhibited
sympathetic nervous system discharge. The other options are
incorrect.

25. 4. Intermittent catherization may be performed chronically with

clean technique, using soap and water to clean the urinary meatus.
The meatus is always cleaned from front to back in a woman, or in
expanding circles working outward from the meatus in a man. It isnt
necessary to measure the urine. The catheter doesnt need to be
rotated during removal.
26. 3. Changes in LOC may indicate expanding lesions such as
subdural hematoma; orientation and LOC are assessed frequently for
24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile
vomiting is a symptom of increased ICP and should be reported
immediately. A slight headache may last for several days after
concussion; severe or worsening headaches should be reported.
27. 1. The frontal lobe primarily functions to regulate thinking,
planning, and affect. Dopamine is known to circulate widely throughout
this lobe, which is why its such an important neurotransmitter in
schizophrenia.
28. 3. An EEG measures the electrical activity of the brain. Extent of
intracranial bleeding and location of the injury site would be
determined by CT or MRI. Percent of functional brain tissue would be
determined by a series of tests.
29. 3. An epidural hematoma occurs when blood collects between the
skull and the dura mater. In a subdural hematoma, venous blood
collects between the dura mater and the arachnoid mater. In a
subarachnoid hemorrhage, blood collects between the pia mater and
arachnoid membrane. A contusion is a bruise on the brains surface.
30. 1. A client with a spinal cord injury at levels C5 to C6 has
quadriplegia with gross arm movement and diaphragmic breathing.
Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory
function. Paraplegia with intercostal muscle loss occurs with injuries at
T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and
bladder control.
31. 3. If the client has a suspected cervical spine injury, a jaw-thrust
maneuver should be used to open the airway. If the tongue or relaxed
throat muscles are obstructing the airway, a nasopharyngeal or
oropharyngeal airway can be inserted; however, the client must have
spontaneous respirations when the airway is open. The head-tilt, chinlift maneuver requires neck hyperextension, which can worsen the
cervical spine injury.
32. 1, 2, 4, 5. The client has signs and symptoms of autonomic
dysreflexia. The potentially life-threatening condition is caused by an
uninhibited response from the sympathetic nervous system resulting
from a lack of control over the autonomic nervous system. The nurse
should immediately elevate the HOB to 90 degrees and place
extremities dependently to decrease venous return to the heart and
increase venous return from the brain. Because tactile stimuli can
trigger autonomic dysreflexia, any constrictive clothing should be

loosened. The nurse should also assess for distended bladder and
bowel impaction, which may trigger autonomic dysreflexia, and correct
any problems. Elevated blood pressure is the most life-threatening
complication of autonomic dysreflexia because it can cause stroke, MI,
or seizures. If removing the triggering event doesnt reduce the clients
blood pressure, IV antihypertensives should be administered. A fan
shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
33. 1. A complication of a head injury is diabetes insipidus, which can
occur with insult to the hypothalamus, the antidiuretic storage vesicles,
or the posterior pituitary gland. Urine output that exceeds 9 L per day
generally requires treatment with desmopressin. Dexamethasone, a
glucocorticoid, is administered to treat cerebral edema. This
medication may be ordered for the head injured patient. Ethacrynic
acid and mannitol are diuretics, which would be contraindicated.
34. 4. The changes in neurological signs from an epidural hematoma
begin with a loss of consciousness as arterial blood collects in the
epidural space and exerts pressure. The client regains consciousness
as the cerebral spinal fluid is reabsorbed rapidly to compensate for the
rising intracranial pressure. As the compensatory mechanisms fail,
even small amounts of additional blood can cause the intracranial
pressure to rise rapidly, and the clients neurological status
deteriorates quickly.
35. 2. After spinal cord injury, the client can develop paralytic ileus,
which is characterized by the absence of bowel sounds and abdominal
distention. Development of a stress ulcer can be detected by hematest
positive NG tube aspirate or stool. A history of diarrhea is irrelevant.
36. 2. The most frequent cause of autonomic dysreflexia is a
distended bladder. Straight catherization should be done every 4 to 6
hours, and Foley catheters should be checked frequently to prevent
kinks in the tubing. Constipation and fecal impaction are other causes,
so maintaining bowel regularity is important. Other causes include
stimulation of the skin from tactile, thermal, or painful stimuli. The
nurse administers care to minimize risk in these areas.
37. 3. Reflex vasodilation below the level of the spinal cord injury
places the client at risk for orthostatic hypotension, which may be
profound. Measures to minimize this include measuring vital signs
before and during position changes, use of a tilt-table with early
mobilization, and changing the clients position slowly. Venous pooling
can be reduced by using Teds (compression stockings) or pneumatic
boots. Vasopressor medications are administered per protocol.
38. 4. Spinal immobilization is necessary after spinal cord injury to
prevent further damage and insult to the spinal cord. Whenever
possible, the client is placed on a Stryker frame, which allows the nurse
to turn the client to prevent complications of immobility, while

maintaining alignment of the spine. If a Stryker frame is not available,

a firm mattress with a bed board should be used.
39. 3. Resolution of spinal shock is occurring when there is a return of
reflexes (especially flexors to noxious cutaneous stimuli), a state of
hyperreflexia rather than flaccidity, reflex emptying of the bladder, and
a positive Babinskis reflex.
40. 3, 1, 4, 2, 5. Autonomic dysreflexia is characterized by severe
hypertension, bradycardia, severe headache, nasal stuffiness, and
flushing. The cause is a noxious stimulus, most often a distended
bladder or constipation. Autonomic dysreflexia is a neurological
emergency and must be treated promptly to prevent a hypertensive
stroke. Immediate nursing actions are to sit the client up in bed in a
high-Fowlers position and remove the noxious stimulus. The nurse
should loosen any tight clothing and then check for bladder distention.
If the client has a foley catheter, the nurse should check for kinks in
the tubing. The nurse also would check for a fecal impaction and
disimpact if necessary. The physician is contacted especially if these
actions do not relieve the signs and symptoms. Antihypertensive
medications may be prescribed by the physician to minimize cerebral
hypertension.
41. 1. Increasing ICP causes unequal pupils as a result of pressure on
the third cranial nerve. Increasing ICP causes an increase in the
systolic pressure, which reflects the additional pressure needed to
perfuse the brain. It increases the pressure on the vagus nerve, which
produces bradycardia, and it causes an increase in body temperature
from hypothalamic damage.
42. 1. Neural control of respiration takes place in the brain stem.
Deterioration and pressure produce irregular respiratory patterns.
Rapid, shallow respirations, asymmetric chest movements, and nasal
flaring are more characteristic of respiratory distress or hypoxia.
43. 3. Normal ICP is 15 mm Hg or less. Hyperventilation causes
vasoconstriction, which reduces CSF and blood volume, two important
factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is
used to control the elevation of temperature because a fever increases
the metabolic rate, which in turn increases ICP. High doses of
barbiturates may be used to reduce the increased cellular metabolic
demands. Fluid volume and inotropic drugs are used to maintain
cerebral perfusion by supporting the cardiac output and keeping the
cerebral perfusion pressure greater than 80 mm Hg.
44. 4. A decrease in the clients LOC is an early indicator of
deterioration of the clients neurological status. Changes in LOC, such
as restlessness and irritability, may be subtle. Widening of the pulse
pressure, decrease in the pulse rate, and dilated, fixed pupils occur
later if the increased ICP is not treated.
45. 2. It is best for the client to wear mitts which help prevent the
client from pulling on the IV without causing additional agitation. Using

a jacket or wrist restraint or tucking the clients arms and hands under
the draw sheet restrict movement and add to feelings of being
confined, all of which would increase her agitation and increase ICP.
46. 4. Decerebrate posturing occurs in patients with damage to the
upper brain stem, midbrain, or pons and is demonstrated clinically by
arching of the back, rigid extension of the extremities, pronation of the
arms, and plantar flexion of the feet. Internal rotation and adduction of
arms with flexion of the elbows, wrists, and fingers described
decorticate posturing, which indicates damage to corticospinal tracts
and cerebral hemispheres.
47. 2. Cluster breathing consists of clusters of irregular breaths
followed by periods of apnea on an irregular basis. A lesion in the
upper medulla or lower pons is usually the cause of cluster breathing.
Because the client had a bleed in the occipital lobe, which is superior
and posterior to the pons and medulla, clinical manifestations that
indicate a new lesion are monitored very closely in case another bleed
ensues. The physician is notified immediately so that treatment can
begin before respirations cease. Another nurse needs to assess vital
signs and score the client according to the GCS, but time is also of the
essence. Checking deep tendon reflexes is one part of the GCS
analysis.
48. 2. Elevating the HOB to 30 degrees is contraindicated for
infratentorial craniotomies because it could cause herniation of the
brain down onto the brain stem and spinal cord, resulting in sudden
death. Elevation of the head of the bed to 30 degrees with the head
turned to the side opposite of the incision, if not contraindicated by the
ICP; is used for supratentorial craniotomies.
49. 2, 3, 4. A client who is brain dead typically demonstrates
nonreactive dilated pupils and nonreactive or absent corneal and gag
reflexes. The client may still have spinal reflexes such as deep tendon
and Babinski reflexes in brain death. Decerebrate or decorticate
posturing would not be seen.
Neuro CVA (Stroke)
9 Regular oral hygiene is an essential intervention for the client
who has had a stroke. Which of the following nursing measures
is inappropriate when providing oral hygiene?
1 Placing the client on the back with a small pillow under the
head.
2 Keeping portable suctioning equipment at the bedside.
3 Opening the clients mouth with a padded tongue blade.
4 Cleaning the clients mouth and teeth with a toothbrush.
10 A 78 year old client is admitted to the emergency department
with numbness and weakness of the left arm and slurred
speech. Which nursing intervention is priority?

1 Prepare to administer recombinant tissue plasminogen

activator (rt-PA).
2 Discuss the precipitating factors that caused the symptoms.
3 Schedule for A STAT computer tomography (CT) scan of the
head.
4 Notify the speech pathologist for an emergency consult.
11 A client arrives in the emergency department with an ischemic
stroke and receives tissue plasminogen activator (t-PA)
administration. Which is the priority nursing assessment?
1 Current medications.
2 Complete physical and history.
3 Time of onset of current stroke.
4 Upcoming surgical procedures.
12 During the first 24 hours after thrombolytic therapy for ischemic
stroke, the primary goal is to control the clients:
1 Pulse
2 Respirations
3 Blood pressure
4 Temperature
13 What is a priority nursing assessment in the first 24 hours after
admission of the client with a thrombotic stroke?
1 Cholesterol level
2 Pupil size and papillary response
3 Vowel sounds
4 Echocardiogram
14 What is the expected outcome of thrombolytic drug therapy?
1 Increased vascular permeability.
2 Vasoconstriction.
3 Dissolved emboli.
4 Prevention of hemorrhage
15 The client diagnosed with atrial fibrillation has experienced a
transient ischemic attack (TIA). Which medication would the
nurse anticipate being ordered for the client on discharge?
1 An oral anticoagulant medication.
2 A beta-blocker medication.
3 An anti-hyperuricemic medication.
4 A thrombolytic medication.
16 Which client would the nurse identify as being most at risk for
experiencing a CVA?
1 A 55-year-old African American male.
2 An 84-year-old Japanese female.
3 A 67-year-old Caucasian male.
4 A 39-year-old pregnant female.
17 Which assessment data would indicate to the nurse that the
client would be at risk for a hemorrhagic stroke?
1 A blood glucose level of 480 mg/dl.

2 A right-sided carotid bruit.

3 A blood pressure of 220/120 mm Hg.
4 The presence of bronchogenic carcinoma.
18 The nurse and unlicensed assistive personnel (UAP) are caring
for a client with right-sided paralysis. Which action by the UAP
requires the nurse to intervene?
1 The assistant places a gait belt around the clients waist prior
to ambulating.
2 The assistant places the client on the back with the clients
head to the side.
3 The assistant places her hand under the clients right axilla to
help him/her move up in bed.
4 The assistant praises the client for attempting to perform
ADLs independently.
9 1. A helpless client should be positioned on the side, not on the
back. This lateral position helps secretions escape from the
throat and mouth, minimizing the risk of aspiration. It may be
necessary to suction, so having suction equipment at the
bedside is necessary. Padded tongue blades are safe to use. A
toothbrush is appropriate to use.
10 3. A CT scan will determine if the client is having a stroke or has
a brain tumor or another neurological disorder. This would also
determine if it is a hemorrhagic or ischemic accident and guide
the treatment, because only an ischemic stroke can use rt-PA.
This would make (1) not the priority since if a stroke was
determined to be hemorrhagic, rt-PA is contraindicated. Discuss
the precipitating factors for teaching would not be a priority and
slurred speech would as indicate interference for teaching.
Referring the client for speech therapy would be an intervention
after the CVA emergency treatment is administered according to
protocol.
11 3. The time of onset of a stroke to t-PA administration is critical.
Administration within 3 hours has better outcomes. A complete
history is not possible in emergency care. Upcoming surgical
procedures will need to be delay if t-PA is administered. Current
medications are relevant, but onset of current stroke takes
priority.
12 3. Controlling the blood pressure is critical because an
intracerebral hemorrhage is the major adverse effect of
thrombolytic therapy. Blood pressure should be maintained
according to physician and is specific to the clients ischemic
tissue needs and risks of bleeding from treatment. Other vital
signs are monitored, but the priority is blood pressure.
13 2. It is crucial to monitor the pupil size and pupillary response to
indicate changes around the cranial nerves. Cholesterol level is

an assessment to be addressed for long-term healthy lifestyle

rehabilitation. Bowel sounds need to be assessed because an
ileus or constipation can develop, but is not a priority in the first
24 hours. An echocardiogram is not needed for the client with a
thrombotic stroke.
14 3. Thrombolytic therapy is use to dissolve emboli and reestablish
cerebral perfusion.
15 1. Thrombi form secondary to atrial fibrillation, therefore, an
anticoagulant would be anticipated to prevent thrombi formation;
and oral (warfarin [Coumadin]) at discharge verses intravenous.
Beta blockers slow the heart rate and lower the blood pressure.
Anti-hyperuricemic medication is given to clients with gout.
Thrombolytic medication might have been given at initial
presentation but would not be a drug prescribed at discharge.
16 1. Africana Americans have twice the rate of CVAs as
Caucasians; males are more likely to have strokes than females
except in advanced years. Orientals have a lower risk, possibly
due to their high omega-3 fatty acids. Pregnancy is a minimal
risk factor for CVA.
17 3. Uncontrolled hypertension is a risk factor for hemorrhagic
stroke, which is a rupture blood vessel in the cranium. A bruit in
the carotid artery would predispose a client to an embolic or
ischemic stroke. High blood glucose levels could predispose a
patient to ischemic stroke, but not hemorrhagic. Cancer is not a
precursor to stroke.
3. This action is inappropriate and would require intervention by the
nurse because pulling on a flaccid shoulder joint could cause shoulder
dislocation; as always use a lift sheet for the client and nurse safety.
All the other actions are appropriate.