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55 Cards in this Set

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  • Back
An elderly client had a stroke and can only see the nasal visual field on one side and the temporal portion on the opposite side. What term describes this condition?
homonymous hemianopia
What is astereognosis?
the inability to identify common objects through touch
What is oculogyric crisis?
a fixed position of the eyeballs that can last for minutes or hours, occurs in response to antipsychotic medications.
What is receptive aphasia?
the inability to understand words or word meaning
A client had an embolic stroke. Which of the following conditions places a client at risk for thromboembolic stroke?
atrial fibrillation occurs with the irregular and rapid discharge from multiple ectopic atrial foci that causes quivering of the atria without atrial systole. ...this asynchronous atrial contraction predisposes to mural thrombi, which may embolize, leading to a stroke.
(Bradycardia, DVT, or past MI won't lead to arterial embolization)
A heparin infusion at 1500 units/hour is ordered for a 65-year-old client with a stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?
An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparain per ml of solution. The equation is set up as 50 units times X (the unknown quanitity) equals 1500 units/hour; X equals 30 ml/hour
Which of the following medications may be presecribed to prevent a thromboembolic stroke?
Ticlopidine inhibits platelet aggregation by interfering with adenosine diphosphate release in the coagulation cascade and is used to prevent thromboembolic stroke.
Does aspirin or acetaminophen interfere with platelet aggregation?
Which medication can be used with evolving myocardial infarctions and dissolves clots.
To maintain airway patency during a stroke in evolution, what position should the patient be placed in?
Because of potential loss of gag reflex and potential altered level of consciousness, the client should be kept in a Fowlers position with tracheal suction available at all times.
To maintain airway patency during a stroke in evolution, don't give thickened dietary liquids until?
gag reflex returns, stroke has evolved, and the deficit can be assessed.
To maintain airway patency during a stroke in evolution, dietary and parenteral fluids DO NOT have to be restricted unless?
heart failure is present.
For a client with a stroke, the following criteria must be fulfilled before the client is fed?
intact gag reflex which shows a properly functioning cranial nerve IX (glossopharyngeal).
True or False? Speech may be normal while the gag reflex is absent?
What kind of diet would be least likely to lead to aspiration in a client who had a stroke with residual dysphagia?
thickened liquids are easiest to form into a bolus and swallow

(clear and liquids are amorphous and can't easily form a bolus...a mechanical soft diet may be too hard to chew and too dry to swallow when dysphagia is present)
A 77-year-old client had a thromboembolic right stroke; his left arm is swollen. What may cause swelling after a stroke?
In clients with hemiplegia or hemiparesis, loss of muscle contaction decreases venous return and may cause swelling of the affected extremity.
A 77-year-old client had a thromboembolic right stroke. There is NO swelling. What musculoskeletal condition might occur?
DVTs are most likely to develop in what part of the body following a stroke?
lower extremity
After a brain stem infarction, a nurse would observe for and why?
bradypnea...vital signs altered

brain stem contains the medullla and vital cardiac center, vasomotor, and respiratory centers
What symptoms may occur with a stroke?
contralateral hemiplegia
numbness or tingling in the
face or arm
Prolonged use of ______ ____ agents is a risk factor for cataracts.
antiinflammatory agents
A client who had cataract surgery should be told to call his physician if has ___?

Other symptoms which might be present are?

blurred vision
Clear fluid is draining from the hose of a client who had a head trauma 3 hours ago. This may indicate what kind of injury?
basilar skull fracture
What is concussion associated with?
brief loss of consciousness, but not necessarily clear fluid loss from the nose following head trauma
A 19-year-old client with mild concussion is discharged from the ER. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. What should the nurse tell the mother?
"Narcotics are avoided after a head injury because they may hide a worsening condition."
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 if?
intracranial pressure is increased (ICP)
A client with head trauma develops a urine output of 300 ml/hour, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform immediately?
evaluate urine specific gravity because a urine output of 300 ml/hour may indicate diabetes insipidus...this may occur with increased intracranial pressure and head trauma...assess for dehydration
Stool softeners would be given to a client after repair of a cerebral aneurysm because?
straining when having a bowel movement, sneezing, coughing, and suctioning may lead to increased ICP and should be avoided when ICP exists.
A client with a subdural hematoma becomes restless and confused, with dilation of ipsilateral pupil. The physician may order mannitol to?
promote osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces...mannitol is used for a lot of things, but the reduction of ICP is of greatest concern here
A client with a subdural hematoma was given mannitol to decrease intracranial pressure (ICP). What result best shows that mannitol was effective?
urine output increases because mannitol promotes osmotic diuresis by increasing theh pressure gradient in the renal tubules
When evaluating an arterial blood gas from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mmHg. What best describes this result?
A normal PaCO2 value is 35 to 45 mmHg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by cerebral dilated cerebral vessels
What kind of shoes following nursing interventions should be used to prevent foot drop and contractures in a client recovering from a subdural hematoma?
high-topped sneakers
A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, and may display this condition due to hemorrhaging?
frequent swallowing...this indicates fluid or blood leaking from the sinuses into the oropharynx
If there is blood or fluid draining from the ear, this may indicate?
basilar skull fracture
Guaiac-positive stools may indicate?
GI bleeding
After a hypophysectomy, vasopressin is given I.M. to?
replace antidiuretic hormone (ADH) normally secreted from the pituitary because after hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH
Which of the following values is considered normal for intracranial pressure?
0 to 15 mmHg
A 33-year-old client undergoes an L4-L5 laminectomy. What mobilization technique would be best to prevent skin breakdown and hypostatic pneumonia?
logrolling...turn the client as a unit by logrolling to prevent stress on the intra-diskal area...DEFINITELY DO NOT teach the client to reach for the side rail because this may cause lordosis of the spine
Voiding small frequent amounts of urine after a lumbar laminectomy may indicate?
urine retention...swelling or pressure on the peripheral nerves control micturition, anesthesia, or use of an indwelling catheter may lead to urine retention with overflow of small frequent amounts of urine
A client with lower back pain and a herniated nucleus pulposus should be taught that strengthening the ______ muscles after laminectomy wil prevent lower back pain.
When preparing a client with suspected herniated nucleus pulposus for myelography, what should the nurse ask the client?
about allergy to iodine
A client is scheduled for chemonucleolysis with chymopapain to relieve the pain of a herniated disk. What should nurse ask patient?
about allergy to meat tenderizers because chymopapain is derived from papaya, an ingredient in meat tenderizers
Why is a Guillain-Barre syndrome patient a priority care over a postappendectomy, postmyocardial infarction, or diverticulis patient?
Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure...G-B is a postviral illness caused by loss of myelin sheath...disorders of airway, breathing, and circulation come first
The cause of myasthenia gravis is?
destruction of acetylcholine receptors causing muscle weakness without atrophy...fatigue is common; muscles of the face and neck primarily involved...m.g. is an autoimmune disorder

(can be treated with Mestinon and Prostigmin)
Parkinson's disease is caused by the inability of ___ ____ to produce sufficient dopamine.
basal ganglia
What is an early visual symptom of myasthenia gravis?
ptosis and diplopia....dysphagia and respiratory distress occur later
One hour after receiving pyridostigmine bromide (Mestinon), a client reports difficulty swallowing and excessive respiratory secretions. What medication should the nurse administer?
atropine...the symptoms suggest cholinergic crisis or excessive acetylcholinesterase medication...
atropine, an anticholinergic drug, is used to antagonize acetylcholinesterase inhibitor
What is ptosis?
dropping or drooping of an organ or part, as the upper eyelid from paralysis, or the visceral organs from weakness of the abdominal muscles
A client with suspected myasthenia gravis is to undergo a Tensilon test. Tensilon is used to diagnose-but not treat-myasthenia gravis. Why isn't it used for treatment?
The duration of action of Tensilon is 1 to 2 minutes, making it impractical for the long-term management of myasthenia gravis
A 20-year-old client with myasthenia gravis will undergo plasmapheresis. What is the purpose of this procedure?
the purpose of plasmapheresis in myasthenia gravis is to separate and remove circulatng acetylcholine receptor antibodies from the blood of clients refractory to the usual therapies or clients in crisis
When assessing a client with glaucoma, what might a nurse expect?
complaints of halos around lights
A client at the eye clinic is newly diagnosed with glaucoma. Noncompliance may lead to?
permanent vision loss
When evaluating the extent of Parkinson's disease, a nurse observes for?
slowing of voluntary muscle movement, muscular rigidity, resting tremor
What is the cause of Parkinson's disease?
degeneration of the substantia nigra in the basal ganglia of the brain where dopamine is produced and stored...depleting dopamine results in motor dysfunction
Multiple sclerosis is characterized by?
loss of myelin sheath around the peripheral nerves