QUESTION SET APPROVED
◉ When a brain-injured patient responds to nail bed pressure with
internal rotation, adduction, and flexion of the arms, how would the
nurse report the response?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing. Answer: c. Decorticate posturing
Internal rotation, adduction, and flexion of the arms in an
unconscious patient is documented as decorticate posturing.
Extension of the arms and legs is decerebrate posturing. Because the
flexion is generalized, it does not indicate localization of pain or
flexion withdrawal.
◉ An athlete is seen in the clinic 6 weeks after a concussion. Which
assessment information will the nurse collect to determine whether
the patient is developing postconcussion syndrome?
a. Short-term memory
,b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil reaction to light. Answer: a. Short-term memory
Decreased short-term memory, persistent headache, lethargy,
personality and behavior changes, shortened attention span, and
changes in intellectual ability are indications of postconcussion
syndrome. The other data may be assessed but are not indications of
postconcussion syndrome.
◉ When assessing a patient who has a right frontal lobe tumor,
which finding would the nurse expect?
a. Expressive aphasia
b. Impaired judgment
c. Right-sided weakness
d. Difficulty swallowing. Answer: b. Impaired judgment
The frontal lobe controls intellectual activities such as judgment.
Speech is controlled in the parietal lobe. Weakness and hemiplegia
occur on the contralateral side from the tumor. Swallowing is
controlled by the brainstem.
,◉ When assessing an adult who has bacterial meningitis, the nurse
obtains the following data. Which finding requires the most
immediate intervention?
a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernig's sign.
c. The patient's temperature is 101F (38.3C).
d. The patient's blood pressure is 88/42 mm Hg.. Answer: d. The
patient's blood pressure is 88/42 mm Hg.
Shock is a serious complication of meningitis, and the patient's low
blood pressure indicates the need for interventions such as fluids or
vasopressors. Nuchal rigidity and a positive Kernig's sign are
expected with bacterial meningitis. The nurse should intervene to
lower the temperature, but this is not as life threatening as the
hypotension.
◉ Which topic would the nurse anticipate teaching a patient who
had a brief episode of tinnitus, diplopia, and dysarthria with no
residual effects?
a. Cerebral aneurysm clipping
b. Heparin intravenous infusion
c. Oral low-dose aspirin therapy
, d. Tissue plasminogen activator (tPA). Answer: c. Oral low-dose
aspirin therapy
The patient's symptoms are consistent with transient ischemic
attack (TIA), and drugs that inhibit platelet aggregation are
prescribed after a TIA to prevent a stroke. Continuous heparin
infusion is not routinely used after TIA or with acute ischemic
stroke. The patient's symptoms are not consistent with a cerebral
aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
◉ A patient is being admitted with a possible stroke. Which
information from the nursing assessment indicates that the patient
is more likely to be having a hemorrhagic stroke than a
thromboembolic stroke?
a. The patient has intermittent bouts of atrial fibrillation.
b. The patient has had brief episodes of right-sided hemiplegia.
c. The patient has a history of treatment for infective endocarditis.
d. The patient reports that the symptoms began with a severe
headache.. Answer: d. The patient reports that the symptoms began
with a severe headache.
A sudden onset headache is typical of a subarachnoid hemorrhage.
Atrial fibrillation and infective endocarditis are a risk factors for
thrombotic or embolic stroke. Brief episodes of right-sided