Author Question: A nursing student studying the neurologic system learns which information? (Select all that apply.) ... (Read 52 times)

Wadzanai · **on:** Jun 25, 2018

A nursing student studying the neurologic system learns which information? (Select all that apply.)

a. An aneurysm is a ballooning in a weakened part of an arterial wall.
b. An arteriovenous malformation is the usual cause of strokes.
c. Intracerebral hemorrhage is bleeding directly into the brain.
d. Reduced perfusion from vasospasm often makes stroke worse.
e. Subarachnoid hemorrhage is caused by high blood pressure.

Question 2

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Assess neurologic status with the Glasgow Coma Scale.
b. Check and document oxygen saturation every 1 to 2 hours.
c. Cluster client care to allow periods of uninterrupted rest.
d. Elevate the head of the bed to 45 degrees to prevent aspiration.
e. Position the client supine with the head in a neutral midline position.

leahchrapun · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A, C, D
An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

Answer to Question 2

ANS: B, E
The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.