NUR 2214 Module 4 EAQs - Questions and Answers

NUR 2214 Module 4 EAQs - Questions and Answers The nurse is caring for a patient with a confirmed thrombotic stroke, whose onset of symptoms began 2 hours earlier. The nurse expects the health care provider to prescribe the administration of which drug? Recombinant tissue plasminogen activator The nurse is recording the output from a Hemovac drain of a patient one-day postoperative following infratentorial craniotomy. For the past eight hours, the total amount of drainage is 45 mL. What action should the nurse take? Continue to monitor the output. Following infratentorial surgery, the normal output for an eight-hour shift is 30 to 50 mL; therefore, 45 mL is expected over eight hours, and the nurse should continue to monitor the output. A patient with a traumatic brain injury from a motor vehicle crash is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for? Changes in breathing pattern Which are advantages of stereotactic radiosurgery (SRS)? Select all that apply. noninvasive decreased cost surgical precision rapid recovery time The nurse is assessing a patient with a traumatic brain injury (TBI) after a skateboarding accident. Which symptom would concern the nurse the most? asymmetrical pupils A patient with a newly diagnosed brain tumor complains of a headache. What medication is likely to be prescribed for this patient? Codeine and acetaminophen (Tylenol, ACE-Tabs) A patient is receiving recombinant tissue plasminogen activator (rtPA) for an acute ischemic stroke. What nursing intervention does the nurse perform first to properly take care of the patient? Ensure that the prescribed follow-up computed tomography (CT) scan is done after treatment is completed and before starting antiplatelet drugs. The registered nurse is teaching a student nurse regarding questions to ask a patient with traumatic brain injury during the assessment. Which statement made by the student nurse indicates ineffective learning? "I will wait until the patient gains consciousness to answer my questions about the injury." The nurse is providing care to a patient with a skull fracture. The nurse notes leakage of fluid from the patient's nose and ears. The magnetic resonance imaging report indicates hemorrhage and damage to the anterior and middle fossal regions of the brain. Which type of fracture does the nurse suspect? A basilar skull fracture The registered nurse is teaching a student nurse about post-surgery management of a patient who underwent supratentorial surgery. Which statement made by the student nurse indicates ineffective learning? "The patient should be placed in a supine position." A patient has experienced a right-hemisphere stroke. What is an important nursing action while caring for this patient? Stand on the patient's left side when talking to increase the visual field. A patient arrives at the emergency department after a motor vehicle accident and indirect injury to the head. Upon assessment, it is discovered that the patient's increased intracranial pressure (ICP) is 18 mm Hg. What is the priority nursing action? Notify the health care provider. A patient has been admitted with a diagnosis of a stroke (brain attack). The nurse suspects that the patient has had a right hemisphere stroke because the patient exhibits which symptoms? Impulsiveness and smiling Which factors contraindicate administering alteplase more than three hours after stroke onset? Select all that apply. Age older than 80 years History of both diabetes and stroke Use of warfarin or other anticoagulants Imaging evidence of middle cerebral artery involvement A patient is brought to the emergency department with aphasia and right-sided hemiplegia. The nurse suspects a stroke in which area of the brain? Left cerebral hemisphere The nurse observes a student nurse care for an adult patient with moderate traumatic brain injury (TBI). Which action made by the student nurse causes the nurse to intervene? Elevating the head of the bed to 15 degrees Which complication results from changes in capillary endothelial tissue permeability, allowing the plasma to seep into the extracellular spaces?