brain swelling Feedback: Brain edema forms around and in damaged neural tissues, contributing to the increasing intracranial pressure. - ANS-Which information should the nurse include when teaching about focal brain injury? Most forms of focal brain injury are associated with increased: Blunt trama Feedback: Head injuries can be classified as closed (blunt) trauma or open (penetrating) trauma. - ANS-The nurse is caring for a patient with a closed head injury. Which term should the nurse use when describing the injury? Frontal. Feedback: Focal brain injuries produced by something striking the front of the head usually produce only coup injuries, or those occurring directly beneath the point of impact. - ANS-A patient's forehead hit the steering wheel during a motor vehicle accident. Which part of the brain received the coup injury. dura mater - ANS-In a patient with an epidural hematoma, the nurse recalls that bleeding occurs between the skull and: Acute subdural hematoma Feedback: Acute subdural hematomas develop within 48 hours of the injury. - ANS-A patient developed a subdural hematoma within 12 hours of the injury. Which diagnosis will the nurse observe documented on the chart? Concussion Feedback: There are two main types of diffuse brain injuries: concussions and diffuse axonal injury. - ANS-Which type of injury will the nurse prepare to care for when a patient has a diffuse brain injury? Spinal shock - ANS-A patient has a recent spinal cord injury. Which term should the nurse use to describe the loss of reflex function below the level of injury/lesion? The nucleus pulposus extrudes and compresses the nerve root. Feedback: A herniated disk allows the gelatinous material (the nucleus pulposus) to extrude and compress the nerve root. - ANS-A nurse is describing the pathophysiology of a herniated disk. Which information should the nurse include? Transient ischemic attack Feedback: The new definition for transient ischemic attack (TIA) is a brief episode of neurologic dysfunction caused by a focal disturbance of brain or retinal ischemia with clinical symptoms typically lasting more than 1 hour; no evidence of infarction; and complete clinical recovery. - ANS-A patient has a brief episode of neurological deficits that resolves within 12 hours with a return to normal functioning. Which diagnosis will the nurse observe documented on the chart? Embolic Feedback: Embolic stroke is commonly associated with atrial fibrillation, myocardial infarction, and valvular heart disease. - ANS-A patient with atrial fibrillation has a stroke. Which type of stroke should the nurse monitor for in this patient? Kernig Feedback: Meningismus (nuchal rigidity) may be elicited through a positive Kernig or Brudzinski sign. - ANS-During the assessment of a patient with meningitis, the nurse wants to test for nuchal rigidity. Which test will the nurse implement? Amyotrophic lateral sclerosis degenerative disorder of both upper and lower motor neurons. Feedback: Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a degenerative disorder of both upper and lower motor neurons that causes progressive muscle weakness and wasting. - ANS-A nurse is preparing a presention on progressive neurological disorders. Which concept should be taught? monitor for respiratory arrest. - ANS-The nurse is caring for a patient with myasthenia gravis. If either a myasthenic or cholinergic crisis occurs, the nurse should: HIV neuropathy Feedback: Painful, burning dysesthesias and paresthesias, typically in the extremities, are present in individuals with HIV neuropathy. - ANS-A patient with HIV has painful burning dysesthesias and paresthesias, especially in the extremities. What condition will the nurse see documented in the chart? The patient is experiencing compression symptoms plus radicular pain. Feedback: Irritative syndromes involve compressive symptoms plus radicular pain and paresthesias. - ANS-A patient has a spinal cord tumor that is causing an irritative syndrome. What does this imply to the nurse? Ependymoma - ANS-A patient has a tumor in the fourth ventricle. Which type of cranial tumor does the nurse suspect? A viral infection