A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-Pa, at what rate should the nurse set the IV pump?
(Record your answer using a decimal rounded to the nearest tenth.) ____ mL/hr
Question 2A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.)
a. Does not want to purchase a thermometer
b. Is allergic to acetaminophen (Tylenol)
c. Laughing, says Strenuous? What's that?
d. Lives alone and is new in town with no friends
e. Plans to have a beer and go to bed once home
Question 3A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activator (t-PA) alteplase (Activase). The client weighs 146 pounds. How much medication will this client receive?
(Record your answer using a whole number.) _____ mg
Question 4A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.)
a. Assess tube placement per agency policy.
b. Keep the head of the bed elevated at least 30 degrees.
c. Listen to lung sounds at least every 4 hours.
d. Run continuous feedings on a feeding pump.
e. Use blue dye to determine proper placement.
Question 5A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)
a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches
b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence
c. Client who had a coil procedure who says that there will be no problem following up for 1 year
d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation
e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
Question 6A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)
a. Client who exhibits extreme emotional lability
b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38
c. Client with mild forgetfulness and a slight limp
d. Client who has a past hospitalization for a suicide attempt
e. Client who is unable to walk or eat 3 weeks post-stroke
Question 7A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Applying a cool washcloth to the head
b. Assisting the client to a position of comfort
c. Keeping voices soft and soothing
d. Maintaining low lighting in the room
e. Providing antipyretics for fever
Question 8A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.)
a. Admission can overwhelm the coping mechanisms for older clients.
b. Alcohol is typically involved in most traumatic brain injuries for this age group.
c. These clients are more susceptible to systemic and wound infections.
d. Other medical conditions can complicate treatment for these clients.
e. Very few traumatic brain injuries occur in this age group.
Question 9A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)
a. Discharging the client on a statin medication
b. Providing the client with comprehensive therapies
c. Meeting goals for nutrition within 1 week
d. Providing and charting stroke education
e. Preventing venous thromboembolism
Question 10A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.)
a. A client with a moderate trauma may need hospitalization.
b. A Glasgow Coma Scale score of 10 indicates a mild brain injury.
c. Only open head injuries can cause a severe TBI.
d. A client with a Glasgow Coma Scale score of 3 has severe TBI.
e. The terms mild TBI and concussion have similar meanings.
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